Sample Answer for PRAC 6635 WEEK 9 Comprehensive Psychiatric Evaluation and Patient Case Presentation 

CC (chief complaint): “Sleeping difficulty.”

HPI: E.S. is a 54-year-old A.A. male who was referred for psychiatric assessment by his PCP. He presented with complaints of sleeping difficulties. He reported having difficulty initiating sleep for the past ten weeks. He also stated that he is usually sleepy when going to bed but often fails to sleep and is forced to get out of bed. This has resulted in sleeping for less than 4 hours a day. The client stated that having minimal sleep has led to daytime fatigue, tiredness, low energy levels, low concentration levels, and reduced work performance. Besides, he reported being constantly moody and lacking interest in most activities because of his low energy levels. The sleeping difficulties were not associated with any medical or psychological condition based on results from the medical assessment by his PCP.

Past Psychiatric History:

• General Statement: No psychiatric history.
• Caregivers (if applicable): None
• Hospitalizations: None
• Medication trials: None
• Psychotherapy or Previous Psychiatric Diagnosis:

Substance Current Use and History: He reports taking 1-2 bottles of beer in the evening to help him fall asleep. He denies tobacco smoking or substance use.

Family Psychiatric/Substance Use History: No family history of psychiatric or substance abuse disorders.

Psychosocial History: E.S. is married and has three children aged 26, 22, and 17. He is a hotel manager with a Degree in Business Management. His hobbies are watching basketball and traveling.

Medical History:

• Current Medications: None
• Allergies: NKDA
• Reproductive Hx: No history of STIs.

ROS:

• GENERAL: Reports fatigue, low energy levels, and sleep disturbance. Denies fever, malaise, or weight changes.
• HEENT: No eye pain, excessive lacrimation, nasal discharge, blockage, or throat pain.
• SKIN: No rashes or bruises.
• CARDIOVASCULAR: No palpitations, SOB, or edema.
• RESPIRATORY: No wheezing, cough, or breathing difficulties.
• GASTROINTESTINAL: No vomiting, appetite changes, abdominal pain, or diarrhea.
• GENITOURINARY: No dysuria, urinary frequency, or urgency.
• NEUROLOGICAL: No headaches, fatigue, or loss of consciousness.
• MUSCULOSKELETAL: No muscle or joint pain.
• HEMATOLOGIC: No bleeding or bruising.
• LYMPHATICS: No enlarged lymph nodes.
• ENDOCRINOLOGIC: No polyuria, acute thirst, hunger, or cold/heat intolerance.

Physical exam:

General: Adult male patient in no acute distress. He appears at the stated age. Normal gait and posture.

Cardiovascular: Regular heart rate and rhythm. S1 and S2 are present. No murmurs.

Respiratory: Chest expands uniformly. Respirations are smooth with no retractions. Lungs clear on auscultation.

Neurological: Speech is clear. C.N.s are intact.

Diagnostic results: No diagnostic tests were needed at this point.

Assessment

Mental Status Examination: The client is well-groomed and dressed appropriately for the weather. The self-reported mood is exhausted, and the affect is euthymic. He appears somewhat bored and tired during the interview session and reports that it is because he is exhausted. His speech is clear, and his thought process is coherent and goal-directed. No delusions, hallucinations, or suicidal ideations were present. He is oriented to person, place, and time. Memory, judgment, abstract thought, and insight are grossly intact.

Differential Diagnoses:

Insomnia: Insomnia is a sleep disorder characterized by poor sleep quantity or quality. Its clinical presentation includes difficulty in initiating or maintaining sleep. It is considered a disorder if it has lasted more than one month. The sleep problems result in daytime impairment (Rosenberg et al., 2023). The patient is having sleeping difficulties with problems initiating sleep and sleeps barely four hours. The sleep impairment has led to daytime impairment due to fatigue, low energy levels, low concentration levels, and reduced work performance.

Depression: Depression is a mood disorder that presents with a depressed or tearful mood or a reduced interest in activities. The diagnostic criteria also include appetite changes, weight changes, sleeping disturbances, low energy levels or fatigue, psychomotor agitation, reduced ability to think and concentrate, feelings of guilt/worthlessness, and suicidal thoughts or ideas (Giannelli, 2020). Depression is a differential diagnosis based on positive symptoms of sleep disturbances, being moody, fatigue, low energy levels, and low concentration levels. However, the symptoms can be attributed to insomnia and not a mood disorder.

Obstructive Sleep Apnea (OSA): This is a sleep disorder characterized by cessation or marked decrease in airflow in the presence of breathing effort. It presents with recurrent episodes of upper airway collapse during sleep (McNicholas & Korkalainen, 2023). Nocturnal symptoms include insomnia, restless sleep with frequent arousals, and tossing or turning during the night. This differential is based on the patient’s report of insomnia.

Reflections: I would ask the client to create a sleep diary in a different patient situation. In the diary, he will record when he goes to bed, falls asleep, awakens during the night, lies in bed awake, and gets out of bed in the morning (Riemann et al., 2023). Social determinants of health (SDOH) affect sleep duration and quality, leading to poorer health and well-being. Siengsukon (2020) explains that some SDOHs that seem to affect sleep include race, ethnicity, socioeconomic status (SES), light exposure, neighborhood safety, and exposure to media and technology. Thus, providing sleep health promotion measures without considering the SDOH that affects sleep health is remiss and thoughtless. Health promotion for this client should include sleep hygiene education to address behaviors incompatible with sleep. The patient should be educated on creating an environment that promotes sleep. This includes mitigating environmental noise, caffeine or alcohol use,  inappropriate room temperature, and watching T.V. in bed.

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.

References

Giannelli, F. R. (2020). Major depressive disorder. Journal of the American Academy of P.A.s, 33(4), 19-20. https://doi.org/10.1097/01.JAA.0000657208.70820.ab

McNicholas, W. T., & Korkalainen, H. (2023). Translation of obstructive sleep apnea pathophysiology and phenotypes to personalized treatment: A narrative review. Frontiers in Neurology, p. 14. https://doi.org/10.3389/fneur.2023.1239016