NRNP/PRAC 6645 Comprehensive Psychiatric Evaluation Note Discussion
CC (chief complaint): family problems
HPI: Patti, an Iranian woman of 40 years who had been recommended for psychiatric examination, walked in with her second-born daughter Sharleen. Domestic abuse and beating by her husband were only two of the horrible experiences her family had to endure. Furthermore, she claimed that her first-born daughter was sexually abused by her father before they departed for the United States. The daughter reportedly moved home with her mother and sisters when the father’s violence became too much to bear, but the daughter has been blaming her mother for the family’s discord ever since. She had first described feeling dismal and powerless, and that her girls were out of control and she had no power over them. Since bringing in their first child, the complete family has been attending therapy sessions together. According to their family therapist, Patti has been adhering to more conventional lifestyle choices, while her daughter has been distancing herself from her in order to adopt a more suitable alternative. NRNP/PRAC 6645 Comprehensive Psychiatric Evaluation Note Discussion This made Patti even more uneasy, as tradition dictates that children should nurse their ailing or elderly parents back to health. Hence, there was conflict because the the children think she should figure out how to make her own way in the world just as they are doing. She had two operations on her feet, which impaired her. She said that she often communicates with Sheela and Shirleen, and that Shirleen had lately moved out and gotten married to someone they did not know.
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Past Psychiatric History:
- General Statement: It has been 18 months since Patti and her children had begun attending family therapy.
- Caregivers (if applicable): N/A
- Hospitalizations: None
- Medication trials: None
- Psychotherapy or Previous Psychiatric Diagnosis: Patti has been involved individual therapy. She and her daughters participate in family therapy. NRNP/PRAC 6645 Comprehensive Psychiatric Evaluation Note Discussion Substance Current Use and History: None reported
Family Psychiatric/Substance Use History: Patti and her daughters participate in family therapy
Psychosocial History: Patti is a woman who hails from Iran and who was both born and reared in that country. She has five children and came to the United States with her family. She considers herself Muslim, but due to a foot problem, she cannot visit the mosque. Her favourite pastimes include playing mobile games and watching religious shows. She said that she is presently living with her son, who is 15 years old, as all of her daughters have left home.
Medical History: Patti has history of foot surgery that failed and left her disabled.
- Current Medications: None reported
- Allergies: Patti is a woman who hails from Iran and who was both born and reared in that country. She has five children and came to the United States with her family. She considers herself Muslim, but due to a foot problem, she cannot visit the mosque. According to rumours, her favourite pastimes include playing mobile games and watching religious shows. She said that she is presently living with her son, who is 15 years old, as all of her daughters have left home.
- Reproductive Hx: Patti has 5 children NRNP/PRAC 6645 Comprehensive Psychiatric Evaluation Note Discussion
ROS:
- GENERAL: Denies fever, chills, night sweats, weight loss, fatigue, or malaise.
- HEENT: Denies headache, visual changes, eye pain, redness, discharge, hearing loss, tinnitus, earache, nosebleeds, nasal congestion, sinus pain or pressure, sore throat, or difficulty swallowing.
- SKIN: Denies rash, itching, lesions, discoloration, or wounds.
- CARDIOVASCULAR: Denies chest pain, palpitations, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, lower extremity edema, or claudication.
- RESPIRATORY: Denies cough, sputum production, hemoptysis, wheezing, or shortness of breath.
- GASTROINTESTINAL: Denies abdominal pain, nausea, vomiting, diarrhea, constipation, blood in stool, or difficulty swallowing.
- GENITOURINARY: Denies dysuria, hematuria, frequency, urgency, incontinence, or discharge.
- NEUROLOGICAL: Denies headache, dizziness, syncope, seizures, weakness, numbness, tingling, tremors, or changes in coordination or balance. NRNP/PRAC 6645 Comprehensive Psychiatric Evaluation Note Discussion
- MUSCULOSKELETAL: Denies joint pain, swelling, stiffness, or limitations in range of motion.
- HEMATOLOGIC: Denies bleeding, bruising, or history of blood disorders.
- LYMPHATICS: Denies lymphadenopathy or history of lymphoma.
- ENDOCRINOLOGIC: Denies changes in appetite, thirst, urination, or energy level, as well as heat or cold intolerance, excessive sweating, or hair loss.
Physical exam: N/A
Diagnostic results: N/A NRNP/PRAC 6645 Comprehensive Psychiatric Evaluation Note Discussion
Assessment
Mental Status Examination: During the assessment, both Patti and Shirleen were appropriately attired, well-groomed, and comfortable. They exhibited signs of alertness and were able to orient themselves to time, place, person, and situation. They conversed fluently and coherently, with an Iranian accent and an average tone. However, Patti was seen raising her voice during arguments with Shirleen. Patti, who used a wheelchair because of her lower limb disability, had a regular gait. She had a logical, target-oriented thought process, without any signs of delusions, hallucinations, or tangentiality. She had a depressed and anxious mood with occasional blunt affect, but denied having any suicidal or homicidal thoughts. Her memory, judgment, and insight were intact, and her concentration was good. Both Patti and Shirleen demonstrated good insight into their current challenges and cooperated during the assessment. Despite Patti’s wheelchair use, she maintained a goal-oriented and logical approach. They were willing and ready to receive help to mend their relationship and prevent it from deteriorating further. NRNP/PRAC 6645 Comprehensive Psychiatric Evaluation Note Discussion
Differential Diagnoses:
- Parent-Child relation problem: This refers to a pattern of interaction between a parent and child that is marked by negative or dysfunctional behavior, and which leads to significant distress and impairment in one or both parties (Linscott & Leve, 2019). Patti and her daughter Sharleen have a strained relationship, as Sharleen is distancing herself from her mother to adopt a more suitable alternative. Patti feels uneasy about this as tradition dictates that children should nurse their ailing or elderly parents back to health. The conflict between them could be indicative of a parent-child relation problem.
- Acculturation Difficulty: This refers to the psychological and social challenges that arise when an individual or a group tries to adjust to a new culture or way of life. This may include issues related to identity, language, social norms, and customs, and can lead to feelings of anxiety, depression, and social isolation (Starck et al., 2021). Patti is adhering to more conventional lifestyle choices, while her daughter is distancing herself from her to adopt a more suitable alternative. This cultural gap could be indicative of an acculturation difficulty. NRNP/PRAC 6645 Comprehensive Psychiatric Evaluation Note Discussion
- Family disruption through divorce and separation: This refers to the process of dissolution of a marital relationship or partnership, and the consequent impact on the children and other family members. This can result in a range of psychological and emotional difficulties for the individuals involved, such as depression, anxiety, anger, and grief, as well as disruptions in family roles and dynamics (Stanick et al., 2018). Patti’s family has been through a lot of turmoil, including domestic abuse and beating by her husband, sexual abuse of her first-born daughter, and violence by her husband. Her first-born daughter has blamed her mother for the family’s discord ever since. Additionally, Shirleen had lately moved out and gotten married to someone they did not know, indicating that there has been some family disruption through divorce and separation. NRNP/PRAC 6645 Comprehensive Psychiatric Evaluation Note Discussion
Case Formulation and Treatment Plan:
Patti is a 40-year-old Iranian woman who came to the United States with her family. She has a history of domestic abuse by her husband and reports that her first-born daughter was sexually abused by him before they moved to the US. Patti feels depressed, powerless, and out of control, and is attending therapy sessions with her family. She has a complicated relationship with her daughters, who are trying to distance themselves from her to adopt more suitable lifestyles. She has a history of foot surgery that failed and left her disabled, and she is living with her 15-year-old son as her daughters have left home. During the assessment, she presented with an anxious and depressed mood, occasional blunt affect, and a logical, target-oriented thought process. It appears that Patti is experiencing symptoms of depression and anxiety, likely resulting from her traumatic experiences of domestic violence, sexual abuse, and family discord. The failed foot surgery and resultant disability may also be contributing to her feelings of powerlessness and frustration. NRNP/PRAC 6645 Comprehensive Psychiatric Evaluation Note Discussion
Treatment Plan:
The treatment plan for Patti and her daughter should be multifaceted, incorporating both individual and family therapy, as well as medical care for her physical disability. The primary goal of therapy should be to help Patti process her trauma and develop coping strategies to manage her depression and anxiety.
Individual Therapy: Patti should be referred to a therapist who specializes in trauma and abuse, such as cognitive-behavioral therapy (CBT) or eye movement desensitization and reprocessing (EMDR). Therapy will focus on helping Patti process her traumatic experiences and develop coping strategies for managing her depression and anxiety symptoms.
Family Therapy: Family therapy sessions should continue, with a focus on improving communication and addressing the family’s ongoing conflicts. The therapist should work with Patti and her daughters to develop strategies for managing the conflict and repairing the relationship.
Medical Care: Patti should be referred to a physician to evaluate her physical disability and explore options for pain management and physical therapy.
Referral: Patti may benefit from a referral to a support group for survivors of domestic violence and/or sexual abuse, where she can connect with others who have experienced similar trauma and receive additional support. NRNP/PRAC 6645 Comprehensive Psychiatric Evaluation Note Discussion
Reflections:
I agree with the preceptor’s assessment that Patti is experiencing depression and anxiety, possibly due to the traumatic events she has experienced in her past. Her feelings of powerlessness, conflicts with her daughter, and disability caused by failed surgery are also contributing factors. The preceptor’s diagnostic impression of depression and anxiety disorder with cultural and social issues is reasonable based on the information provided.
This case highlights the importance of considering the social determinants of health and the patient’s background when evaluating their mental health. Patti’s history of domestic violence, cultural background, and socioeconomic status may have contributed to her current mental health status. Health promotion and disease prevention strategies should consider the patient’s cultural background and beliefs to provide more effective care. NRNP/PRAC 6645 Comprehensive Psychiatric Evaluation Note Discussion
From this case, I learned the importance of cultural sensitivity and understanding when evaluating a patient’s mental health. It is also essential to consider the patient’s social and economic background to provide more holistic care. Furthermore, it is vital to recognize the impact of traumatic events, such as domestic violence, on a patient’s mental health.
Regarding legal/ethical considerations, it is essential to recognize that domestic violence is a form of abuse and a crime. Mental health professionals have a legal and ethical obligation to report suspected cases of abuse to the appropriate authorities. It is also important to ensure that the patient’s confidentiality is maintained throughout the evaluation and treatment process. NRNP/PRAC 6645 Comprehensive Psychiatric Evaluation Note Discussion
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References
Linscott, J. G., & Leve, L. D. (2019). Parent-Child and Sibling Relational Problems. Handbook of DSM-5 Disorders in Children and Adolescents, 565-581.
Stanick, C. F., Crosby, L. K., & McDonald, M. K. (2018). Family Disruption. Handbook of DSM-5 Disorders in Children and Adolescents, 583-595.
Starck, A., Gutermann, J., Schouler-Ocak, M., Jesuthasan, J., Bongard, S., & Stangier, U. (2020). The relationship of acculturation, traumatic events and depression in female refugees. Frontiers in Psychology, 11, 906.
Masterswork Productions. (2003). Mother and daughter: A cultural taleLinks to an external site. [Video/DVD]. https://go.openathens.net/redirector/waldenu.edu?url=https://video.alexanderstreet.com/watch/mother-and-daughter-a-cultural-tale
Document the following for the family in the video, using the Comprehensive Evaluation Note Template:
Chief complaint
History of present illness
Past psychiatric history
Substance use history
Family psychiatric/substance use history
Psychosocial history/Developmental history NRNP/PRAC 6645 Comprehensive Psychiatric Evaluation Note Discussion
Medical history
Review of systems (ROS)
Physical assessment (if applicable)
Mental status exam
Differential diagnosis—Include a minimum of three differential diagnoses and include how you derived each diagnosis in accordance with DSM-5-TR diagnostic criteria
Case formulation and treatment plan
Include a psychotherapy genogram for the family
Note: For any item you are unable to address from the video, explain how you would gather this information and why it is important for diagnosis and treatment planning. NRNP/PRAC 6645 Comprehensive Psychiatric Evaluation Note Discussion