Comprehensive Psychiatric Evaluation and Patient Case Presentation

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

Student Name

College of Nursing-PMHNP, Walden University

NRNP 6635: Psychopathology and Diagnostic Reasoning

Faculty Name

Assignment Due Date

NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template

CC (chief complaint):

HPI:

Past Psychiatric History:

· General Statement:

· Caregivers (if applicable):

· Hospitalizations:

· Medication trials:

· Psychotherapy or Previous Psychiatric Diagnosis:

Substance Current Use and History:

Family Psychiatric/Substance Use History:

Psychosocial History:

Medical History:

· Current Medications:

· Allergies:

· 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:

References

NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Exemplar

(The comprehensive evaluation is typically the initial new patient evaluation. You will practice writing this type of note in this course. You will be ruling out other mental illnesses so often you will write up what symptoms are present and what symptoms are not present from illnesses to demonstrate you have indeed assessed for all illnesses which could be impacting your patient. For example, anxiety symptoms, depressive symptoms, bipolar symptoms, psychosis symptoms, substance use, etc.)

CC (chief complaint): A brief statement identifying why the patient is here. This statement is verbatim of the patient’s own words about why presenting for assessment. For a patient with dementia or other cognitive deficits, this statement can be obtained from a family member.

HPI: Begin this section with patient’s initials, age, race, gender, purpose of evaluation, current medication and referral reason. For example:

N.M. is a 34-year-old Asian male presents for psychiatric evaluation for anxiety. He is currently prescribed sertraline which he finds ineffective. His PCP referred him for evaluation and treatment.

Or

P.H., a 16-year-old Hispanic female, presents for psychiatric evaluation for concentration difficulty. She is not currently prescribed psychotropic medications. She is referred by her therapist for medication evaluation and treatment.

Then, this section continues with the symptom analysis for your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis.

Paint a picture of what is wrong with the patient. This section contains the symptoms that is bringing the patient into your office. The symptoms onset, duration, frequency, severity, and impact. Your description here will guide your differential diagnoses. You are seeking symptoms that may align with many DSM-5 diagnoses, narrowing to what aligns with diagnostic criteria for mental health and substance use disorders.

Past Psychiatric History: This section documents the patient’s past treatments. Use the mnemonic Go Cha MP.

General Statement: Typically, this is a statement of the patients first treatment experience. For example: The patient entered treatment at the age of 10 with counseling for depression during her parents’ divorce. OR The patient entered treatment for detox at age 26 after abusing alcohol since age 13.

Caregivers are listed if applicable.

Hospitalizations: How many hospitalizations? When and where was last hospitalization? How many detox? How many residential treatments? When and where was last detox/residential treatment? Any history of suicidal or homicidal behaviors? Any history of self-harm behaviors?

Medication trials: What are the previous psychotropic medications the patient has tried and what was their reaction? Effective, Not Effective, Adverse Reaction? Some examples: Haloperidol (dystonic reaction), risperidone (hyperprolactinemia), olanzapine (effective, insurance wouldn’t pay for it)

Psychotherapy or Previous Psychiatric Diagnosis: This section can be completed one of two ways depending on what you want to capture to support the evaluation. First, does the patient know what type? Did they find psychotherapy helpful or not? Why? Second, what are the previous diagnosis for the client noted from previous treatments and other providers. Thirdly, you could document both. Comprehensive Psychiatric Evaluation and Patient Case Presentation

Substance Use History: This section contains any history or current use of caffeine, nicotine, illicit substance (including marijuana), and alcohol. Include the daily amount of use and last known use. Include type of use such as inhales, snorts, IV, etc. Include any histories of withdrawal complications from tremors, Delirium Tremens, or seizures.

Family Psychiatric/Substance Use History: This section contains any family history of psychiatric illness, substance use illnesses, and family suicides. You may choose to use a genogram to depict this information. Be sure to include a reader’s key to your genogram or write up in narrative form.

Social History: This section may be lengthy if completing an evaluation for psychotherapy or shorter if completing an evaluation for psychopharmacology. However, at a minimum, please include:

Where patient was born, who raised the patient

Number of brothers/sisters (what order is the patient within siblings)

Who the patient currently lives with in a home? Are they single, married, divorced, widowed? How many children?

Educational Level

Hobbies:

Work History: currently working/profession, disabled, unemployed, retired?

Legal history: past hx, any current issues?

Trauma history: Any childhood or adult history of trauma?

Violence Hx: Concern or issues about safety (personal, home, community, sexual (current & historical)

Medical History: This section contains any illnesses, surgeries, include any hx of seizures, head injuries.

Current Medications: Include dosage, frequency, length of time used, and reason for use. Also include OTC or homeopathic products.

Allergies: Include medication, food, and environmental allergies separately. Provide a description of what the allergy is (e.g., angioedema, anaphylaxis). This will help determine a true reaction vs. intolerance.

Reproductive Hx: Menstrual history (date of LMP), Pregnant (yes or no), Nursing/lactating (yes or no), contraceptive use (method used), types of intercourse: oral, anal, vaginal, other, any sexual concerns

ROS: Cover all body systems that may help you include or rule out a differential diagnosis. Please note: THIS IS DIFFERENT from a physical examination!

You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.

Example of Complete ROS:

GENERAL: No weight loss, fever, chills, weakness, or fatigue.

HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.

SKIN: No rash or itching.

CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.

RESPIRATORY: No shortness of breath, cough, or sputum.

GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.

GENITOURINARY: Burning on urination, urgency, hesitancy, odor, odd color

NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness.

HEMATOLOGIC: No anemia, bleeding, or bruising.

LYMPHATICS: No enlarged nodes. No history of splenectomy.

ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.

Physical exam (If applicable and if you have opportunity to perform—document if exam is completed by PCP): From head to toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head-to-toe format i.e., General: Head: EENT: etc.

Diagnostic results: Include any labs, X-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines).

A ssessment

Mental Status Examination: For the purposes of your courses, this section must be presented in paragraph form and not use of a checklist! This section you will describe the patient’s appearance, attitude, behavior, mood and affect, speech, thought processes, thought content, perceptions (hallucinations, pseudohallucinations, illusions, etc.)., cognition, insight, judgment, and SI/HI. See an example below. You will modify to include the specifics for your patient on the above elements—DO NOT just copy the example. You may use a preceptor’s way of organizing the information if the MSE is in paragraph form.

He is an 8-year-old African American male who looks his stated age. He is cooperative with examiner. He is neatly groomed and clean, dressed appropriately. There is no evidence of any abnormal motor activity. His speech is clear, coherent, normal in volume and tone. His thought process is goal directed and logical. There is no evidence of looseness of association or flight of ideas. His mood is euthymic, and his affect appropriate to his mood. He was smiling at times in an appropriate manner. He denies any auditory or visual hallucinations. There is no evidence of any delusional thinking.   He denies any current suicidal or homicidal ideation. Cognitively, he is alert and oriented. His recent and remote memory is intact. His concentration is good. His insight is good.

Differential Diagnoses: You must have at least three differentials with supporting evidence. Explain what rules each differential in or out and justify your primary diagnosis selection. Include pertinent positives and pertinent negatives for the specific patient case.

Also included in this section is the reflection. Reflect on this case and discuss whether or not you agree with your preceptor’s assessment and diagnostic impression of the patient and why or why not. What did you learn from this case? What would you do differently?

Also include in your reflection a discussion related to legal/ethical considerations (demonstrating critical thinking beyond confidentiality and consent for treatment!), health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.). Comprehensive Psychiatric Evaluation and Patient Case Presentation

References

You are required to include at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines which relate to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting.

PLEASE FOLLOW THE INSTRUCTIONS AS INDICATED BELOW:

 

1). ZERO (0) PLAGIARISM

 

2). AT LEAST 5 REFERENCES, NO MORE THAN 5 YEARS (WITHIN 5YRS, OR LESS THAN 5YRS)

 

3). PLEASE SEE THE ATTACHED RUBRIC DETAILS, Comprehensive Psychiatric Evaluation Exemplar, Comprehensive Psychiatric Evaluation Template, My Patient’s comprehensive evaluation.

 

4). Please review and follow the grading rubric details, and include each component in the assignment as required. Also, follow the APA 7 writing rules and style/Format.

Initial Eval. 09/21/2021

 

CC (Chief Complaint) The patient stated, “I have lots of pressure at home and at work”.

 

 

VITAL SIGNS 

Height: 5’6”

Weight: 272 lbs.

Blood Pressure: 132/68

Temperature: 97.3

Pulse: 76

Respiratory rate: 18

O2 Saturation: 98

Pain: No pain

 

Diagnosis: Major Depression disorder, Insomnia

 

Allergies: Patient has no known drug, food, or environmental allergies

 

Medications

Mirtazapine 15 MG Oral Tablet

Take 1 tablet (15 mg) by mouth daily at bedtime.

 

Smoking history: Non-smoker

 

Gender identity: Female

 

Sexual Orientation: Heterosexual

 

Social history: Working for 17 years. Has a good relationship with peers.

 

Past Medical History: Mood issue.

 

Ongoing medical problems: Problems in the house.

 

Family health history: Brother has mood problems.

No other family member has any disorder.

 

Preventive care: Lives with her children.

 

Nutrition history: Eats poorly

 

Developmental history: Normal birth.

 

Subjective:

Patient is a 41-year-old Hispanic female who has been presented for initial evaluation with consent. Weight: 272 lbs. Height: 5’6″. Patient stated, “I have pressure at home and at work”. She reported, “I don’t feel very good, I concentrate at work, but I don’t get enough sleep, and I barely eat much”. She reported that her mood goes up and down, and sometimes she cries herself to sleep. She stated that she resides in the state of Maryland with her 4 children, ages 21-, 13-, and 6-years old tweens, and raising them alone. She reported that she is married, but husband is still in their country (Mexico). She reported that she has been struggling with this issue for sometimes now. She stated that she resides in the state of Maryland.

 

Objective:

The patient is alert and oriented 4, to person, place, time and the situation. She verbally responded to questions appropriately with intact memories. Patient reported having pressure at home and at work. She reported not sleeping good and barely eating each day. She reported that her mood is up and down, and sometimes she cries herself to sleep. The mood is euthymic, and affect is congruent with mood. Thought process is linear, goal-directed, and coherent. She denies any suicidal or homicidal ideation intent or plans at this time. Denies visual or auditory hallucinations, delusions, or paranoia. Comprehensive Psychiatric Evaluation and Patient Case Presentation

Further evaluation of mental status reveals the following:

 

 

MENTAL STATUS EXAMINATION

General appearance: Appropriate, calm and cooperative with good eye contact.

Attitude: Good

Behavior: normal

Speech: Normal

Mood: Anxious

Affect: Euthymic

Thought Process:   Goal directed

Thought Content: Normal

perceptions: Fair

Insight: Very good insight

judgment: Good

cognition: Good

Memory: Intact

 

 

 

 

 

Assessment:

The patient is a 41-year-old female that presents today for an initial evaluation via telehealth, consents obtained.

Patient described her chief complaint as having lots of pressure at home and at work. She reported not sleeping good at all, and barely eat each day. She stated that she cries herself to sleep most of the time. After assessing patient, provider diagnosed patient for major depressive disorder and patient stated, “you are 100% correct”. Provider prescribed Mirtazapine 15 mg for depression, also to aide in insomnia. She is educated on the importance of taking her medication as prescribed. She was encouraged using coping skills to help stabilize her mood and life style change (e.g., walking, exercise, eating right, drinking lot of water). She was also educated on the medication, its interactions, and side effects, and she verbalized understanding. Patient verbalized that she has no further concerns at this time. Provider will fill the medication at the preferred pharmacy, and she is instructed to pick it up from the pharmacy. Provider recommended therapy and patient agreed. Follow up visit in 2 weeks on 10/5/2021.

Patient is encouraged to call 911 for suicidal or homicidal ideation.

 

 

 

Plan of Care

The plan is to maintain stability from depression, poor appetite and insomnia over the next 90 days

Continue Mirtazapine 15 mg

Educated on medication and medication interactions.

Educated on the use of positive coping skills.

Instructed to report any medication side effects or drug interactions. Verbalized understanding.

Encourage to engage in healthy lifestyle

Medication is sent to pharmacy

Follow up in 2 weeks on 10/5//21 at 3:30 pm.

Call 911 for suicidal or homicidal ideation.

 

 

 

Medications: Mirtazapine 15 MG Oral Tablet

Take 1 tablet (15 mg) by mouth daily at bedtime