Case 15 comprehensive psychiatric evaluation

CASE 15: VOICES COMMENT ON EVERYTHING I DO

History A 24-year-old man presents to hospital having got into a fight as he thought he was being watched and felt threatened. He appears to have fractured his thumb but is reluctant to let you examine him or order an X-ray. He looks suspicious and wary. When asked about his concerns he says that over the last few months he has been carefully monitored by government agencies. He has been hearing a voice out loud giving a running commentary on his thoughts and these are being broadcast to the government. Any machine enables the government to get inside his head and the voice is telling him it would be unwise to face the X-ray machine. The voice is not one that he recognizes, and it is sometimes derogatory, telling him he is stupid for giving his thoughts away for free. Initially the voice came and went but over the last few weeks it is present almost constantly and he cannot always sleep because even when he sleeps the voice comments on what he is thinking. He is exhausted. The man is absolutely convinced that the government is after him but he cannot explain why. There is no previous history and he denies any substance use. Until a few weeks ago he had been working as a kitchen assistant but was sacked for leaving jobs unfinished. There is no family history of any psychiatric illness.

Mental state examination

The man looks unkempt. He is wary and looks quite frightened and agitated. His eye contact is fleeting and he constantly looks around him in a perplexed manner. His speech is rambling and he does not express himself coherently. He occasionally uses words that you have not heard before and repeats them as though they have some significance. He does not come across as depressed. He has delusions of persecution. He has auditory hallucinations that provide a running commentary on every aspect of his behaviour. He has thought broadcast and thought withdrawal. He is orientated in person, but unclear about the time. He seems aware that he is in hospital but not quite sure why

Week (enter week #): (Enter assignment title)

Student Name

College of Nursing-PMHNP, Walden University

PRAC 6635: Psychopathology and Diagnostic Reasoning

Faculty Name

Assignment Due Date

NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template

CC (chief complaint):

HPI:

Past Psychiatric History:

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General Statement:

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Caregivers (if applicable):

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Hospitalizations:

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Medication trials:

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Psychotherapy or
Previous Psychiatric Diagnosis:

Substance Current Use and History:

Family Psychiatric/Substance Use History:

Psychosocial History:

Medical History:

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Current Medications:

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Allergies:

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Reproductive Hx:

ROS:

· GENERAL:

· HEENT:

· SKIN:

· CARDIOVASCULAR:

· RESPIRATORY:

· GASTROINTESTINAL:

· GENITOURINARY:

· NEUROLOGICAL:

· MUSCULOSKELETAL:

· HEMATOLOGIC:

· LYMPHATICS:

· ENDOCRINOLOGIC:

Physical exam: if applicable

Diagnostic results:

Assessment

Mental Status Examination:

Differential Diagnoses:

Reflections:

PRECEPTOR VERFICIATION:

I confirm the patient used for this assignment is a patient that was seen and managed by the student at their Meditrek approved clinical site during this quarter course of learning.

Preceptor signature: ________________________________________________________

Date: ________________________

References