During the patient evaluation, A.P. provided information about their personal and medical history. They reported a complex psychiatric history, including diagnoses of schizoaffective disorder, autism spectrum disorder, OCD, depression, anxiety, bipolar disorder, and mild intellectual disability

QUESTION

CC: Paranoia

HPI: A.P. is a 37yr old Caucasian male diagnosed with schizoaffective disorder, autism spectrum disorder, OCD, depression, anxiety, bipolar disorder, and mild intellectual disability. The patient presented to E.D. with a complaint of increased anxiety and paranoia. Per the triage note, the patient reported fears of getting hit by a car, fear of the dark, and fear that people are out to get the patient. The patient’s family told the provider they were concerned about increased delusions and risk of harm to others. The patient’s family reported patient has been compliant with medications. The patient’s family discussed increased aggression and paranoia of getting hit by a car if the patient went outside. The patient’s family reported patient addressed the desire to hurt the mailman with a steak knife. According to the patient’s family, the patient did not act on thought to hurt the mailman. The patient denied suicidal ideation and homicidal ideation in triage. The patient’s father presented during the assessment to help with collateral information. The patient’s father discussed noticing that the patient’s anxiety and paranoia related to fears have increased over the last two weeks. A.P.’s father addressed the patient’s fears of being hit by cars, wanting to have everyone believe in God, people to not drink alcohol, and increased worry about people the patient is around. The father reported pt seemed to have been doing better recently since his last inpatient hospitalization. The father also stated patient recently had an increased dosage of Invega, and he is also concerned that the patient does not see a positive benefit from the dosage change. The father stated that the dosage change occurred two weeks before the E.D. visit. The father discussed concern for the patient’s recent behavioral outbursts around community members, including the patient talking about wanting to hurt the “worldwide truck drivers.” UPS and the recent posturing patient did towards someone that pulled into the family business parking lot. The patient’s father discussed having no worries that the patient would hurt anyone or himself during the E.D. visit but discussed concern for the patient’s potential to hurt others. The patient’s father discussed no problem with the patient’s safety during the assessment process and no concern for community safety.

1. Subjective: What details did the patient provide regarding their personal and medical history?

• What are their symptoms of concern?
• How long have they been experiencing them, and what is the severity?
• How are their symptoms impacting their functioning?

2. Objective: What observations did you make during the interview and review of systems?

3. Assessment: What were your differential diagnoses? Provide a minimum of three (3) possible diagnoses. List them from highest to lowest priority.

What was your primary diagnosis, and why?

4. Diagnostics/Labs/Psych screening tools: Please Discuss diagnostics and Psychiatric tools with evidence-based results.

5. Reflection notes:

• What would you do differently in a similar patient evaluation?
• Reflect on one social determinant of health according to HealthyPeople 2030 (you will need to research) as applied to this case in the realm of psychiatry and mental health.
• As a future advanced provider, what are one health promotion activity and one patient education considerations for this patient to improve health disparities and inequities in psychiatry and mental health?
• Demonstrate your critical thinking.

Please list 5 scholarly references and citations under five years old so I can further research. 

I appreciate any help you can provide. References can not be over five years old.

School References: Recommended

American Psychiatric Association. (2022). Sexual dysfunctionsLinks to an external site. In Diagnostic and statistical manual of mental disorders (5th ed., text rev.).

American Psychiatric Association. (2022). Personality disordersLinks to an external site, in Diagnostic and statistical manual of mental disorders (5th ed., text rev.).

American Psychiatric Association. (2022). Paraphilic disordersLinks to an external site. In Diagnostic and statistical manual of mental disorders (5th ed., text rev.).

• Boland, R. Verdiun, M. L. & Ruiz, P. (2022). Kaplan & Sadock’s synopsis of psychiatry (12th ed.). Wolters Kluwer.

ANSWER

Subjective

During the patient evaluation, A.P. provided information about their personal and medical history. They reported a complex psychiatric history, including diagnoses of schizoaffective disorder, autism spectrum disorder, OCD, depression, anxiety, bipolar disorder, and mild intellectual disability. The patient complained of increased anxiety and paranoia, with fears of getting hit by a car, fear of the dark, and a belief that people are out to harm them. The patient’s family expressed concerns about increased delusions and potential harm to others, particularly mentioning thoughts of hurting the mailman with a steak knife. The patient’s anxiety and paranoia had escalated over the past two weeks, and they recently experienced increased behavioral outbursts.

Objective

During the interview and review of systems, the healthcare provider observed A.P.’s increased anxiety, paranoid thoughts, and agitated behavior. The patient appeared distressed and preoccupied with their fears, which seemed to impact their functioning and ability to interact with others.

Assessment

Differential Diagnoses

Schizoaffective Disorder: Given the combination of psychotic and mood symptoms, schizoaffective disorder is a primary differential diagnosis.
Obsessive-Compulsive Disorder (OCD): OCD is considered due to the presence of intrusive and distressing thoughts (obsessions) and the patient’s engagement in rituals or mental acts to alleviate anxiety (compulsions).
Generalized Anxiety Disorder (GAD): GAD is considered based on the excessive worry and apprehension reported by the patient.

 Primary Diagnosis

Schizoaffective Disorder: This is the primary diagnosis due to the presence of psychotic symptoms (delusions) alongside mood symptoms (increased anxiety and depression).

Diagnostics/Psychiatric Screening Tools

To confirm the diagnosis and guide treatment, the following assessments are recommended:
Structured Clinical Interview for DSM-5 (SCID): A standardized diagnostic interview tool to assess for various psychiatric disorders, including schizoaffective disorder.
Yale-Brown Obsessive-Compulsive Scale (Y-BOCS): A tool to measure the severity of OCD symptoms, if applicable.
Generalized Anxiety Disorder 7 (GAD-7): A self-report tool to assess the severity of anxiety symptoms.

Reflection Notes

Improving Patient Evaluation: In a similar patient evaluation, I would ensure a comprehensive assessment of the patient’s psychiatric history, current symptoms, and potential risk of harm to self or others. Additionally, I would involve collateral sources, such as family members, to gather a more comprehensive understanding of the patient’s condition.

Social Determinant of Health: One relevant social determinant of health for this case is “Access to Mental Health Services.” Ensuring equal access to quality mental health services is crucial in addressing mental health disparities and promoting overall well-being.

Health Promotion Activity: Implementing community-based mental health programs that focus on early intervention and support for individuals with severe mental illnesses can improve health disparities. Patient Education: Providing psychoeducation to the patient and their family about the importance of medication adherence, symptom management, and coping strategies can improve the patient’s understanding of their condition and foster a more supportive environment.