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ComprehensivePsychiatricEvaluation2.docx
Comprehensive Psychiatric Evaluation Template
With Psychotherapy Note
Encounter date: _________21/03/2023_______________
Patient Initials: __R.S.____ Gender: M/F/Transgender _Male___ Age: __19___ Race: _Caucasian____ Ethnicity __White__
Reason for Seeking Health Care: “I am experiencing uncontrollable intrusive thoughts and compulsions that are making it difficult for me to function and are making me extremely anxious.”
HPI: The patient is a 19-year-old male who comes to the clinic with his friend. The patient presents with a history of anxiety and intrusive thoughts. According to the patient, he has spent the last six months worrying excessively and having phobias related to hygiene and contamination. The patient characterizes these ideas as bothersome and upsetting, and he has been having a lot of trouble suppressing them. The patient admitted that, although it has never been extreme, he has always had a dislike of dirt or germs. The patient admitted that for the previous six months, he had felt the impulse to stay in his house to avoid being contaminated. The patient admitted that his regular hand washing for 20 minutes throughout the day whenever he leaves the house is hindering his productivity at work. He characterizes his thoughts as upsetting, unreasonable, and persistent. He said that he frequently goes for hours worrying and trying to regulate his thoughts. The patient admitted that he came to the clinic because he wanted to learn how to manage these urges and intrusive thoughts so that he could live properly. The patient admitted the severity of his symptoms being at an 8/10 with 10 being the most severe. He denied having suicidal, self-destructive, or murderous impulses.
SI/HI: __The patient denied that having had any thoughts of suicide or homicide recently or in the past.
Sleep: _The patient claims not to experience any sleep issues, such as trouble initiating sleep, maintaining it, or waking up in the morning.
Appetite: _ The patient denied having observed any alterations in their appetite, including increased cravings, decreased hunger, or a heightened dislike for specific foods.
Allergies (Drug/Food/Latex/Environmental/Herbal): The patient admitted that upon consuming eggs or any food that contains eggs, he typically experiences a moderate allergic reaction that manifests as itchiness, a runny nose, and watery eyes. Current perception of Health: Excellent Good Fair Poor
Psychiatric History:
Inpatient hospitalizations:
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Date |
Hospital |
Diagnoses |
Length of Stay |
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None
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None
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None
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None
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Outpatient psychiatric treatment:
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Date |
Hospital |
Diagnoses |
Length of Stay |
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None
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None
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None
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None
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None
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None
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None
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None
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Detox/Inpatient substance treatment:
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Date |
Hospital |
Diagnoses |
Length of Stay |
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None
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None
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None
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None
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None
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None
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None
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None
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History of suicide attempts and/or self-injurious behaviors: ______ The patient denied having instances of suicidal attempts or self-injurious behaviors, neither presently or in the past.
Past Medical History
· Major/Chronic Illnesses_ The patient denied having been diagnosed with any chronic or significant illnesses.
· Trauma/Injury ___ The patient admitted that at the age of 18, he fell down the stairs and fractured his arm, which eventually healed. However, he denied any recent injuries or traumatic incidents.
· Hospitalizations ___The patient denied having ever been hospitalized for any medical issue.
Past Surgical History___ The patient denied any surgical procedure being performed on him recently or in the past.
Current psychotropic medications:
___________None______________________________ _____________________________
________________________________________
Current prescription medications:
___________None_________________
_________________________________________
OTC/Nutritionals/Herbal/Complementary therapy:
_________________________________________ ________________________________
Substance use : (alcohol, marijuana, cocaine, caffeine, cigarettes)
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Substance |
Amount |
Frequency |
Length of Use |
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None |
None |
None |
None |
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None |
None |
None |
None |
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None |
None |
None |
None |
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None |
None |
None |
None |
Family Psychiatric History:
· The patient's father, who is 56 years old currently, has a medical history of generalized anxiety disorder and hypertension.
· The patient's mother, who is 48 years old, was diagnosed with compulsive obsessive disorder when she was 12 years-old.
· The patient's paternal grandfather passed away at 81 years old and had a history of major depressive disorder and post-traumatic stress disorder, although the patient cannot recall the exact year of diagnosis.
· The patient's older brother, currently 27 years-old, was diagnosed with generalized anxiety disorder when he was 15 years-old and panic disorder when he was 25 years old.
Social History
Lives: Single family House/Condo/ with stairs: ___two-bedroom apartment________ Marital Status: __ _Single_____
Education: ______ Bachelor of Accounting and Finance ______________________
Employment Status: __ Employed part-time___ Current/Previous occupation type: _____ Part-time accountant at his family’s law firm ____________
Exposure to: __Denies _Smoke_ _Denies__ ETOH __Denies_ _Recreational Drug Use: __________________
Sexual Orientation: ____Heterosexual___ Sexual Activity: __Active__ Contraception Use: _________Condoms___
Family Composition: Family/Mother/Father/Alone : __The patient’s father and mother are currently alive. He has one older brother who is married and lives in a different state.
Other: (Place of birth, childhood hx, legal, living situations, hobbies, abuse hx, trauma, violence, social network, marital hx): ___ The patient admitted that he was born in Miami, Florida, and is presently living alone in a two-bedroom apartment. He admitted that he is currently pursuing a Bachelor's degree in Accounting and Finance and working part-time as an accountant for his family's law firm. Additionally, he admitted that during his free time, he enjoys cooking, reading, and listening to music. The patient admitted having a large social circle and denied any involvement in violence or abuse.
Health Maintenance
Screening Tests (submit with SOAP note): Depression, Anxiety, ADHD, Autism, Psychosis, Dementia
· The patient admitted to having a complete physical examination, including height, weight, blood pressure, and body mass index performed every year to assess his overall health. He admitted next visit is on 4th of September 2023.
· The patient admitted to only being screened for anxiety using the Generalized Anxiety Disorder 7- item(GAD-7).
· The patient admitted to sticking to a regular exercise routine for 2 hours every morning.
· The patient admitted to having a dental health examination every six months. He admits to getting education on good oral hygiene practices at the visit.
Exposures: The patient denied being exposed to any harmful substances
Immunization HX:
· The patient admitted to a recent Tdap booster shot for tetanus, diphtheria, and pertussis on January 3rd 2023 as he had not had one in the past 10 years. The patient admitted all his immunization schedule is up-to-date.
Review of Systems (at least 3 areas per system):
General: The patient appears well-nourished and in no acute distress. The patient denies any fever, chills, or night sweats. The patient denies any recent significant weight gain or loss. The patient admits experiencing increased anxiety and stress.
HEENT: The patient denies having headache, dizziness, or lightheadedness. The patient denies any history of head injury or concussion. The patient denies no changes in vision or eye discomfort, including no eye redness, itching, or discharge. The patient denies no hearing loss, ringing in the ears, or ear pain. The patient denies any history of nasal congestion, sinus pressure, or nosebleeds. The patient denies no difficulty swallowing, sore throat, or hoarseness.
Neck: The patient denies any stiffness or soreness in the neck. no prior history of enlarged lymph nodes.
Lungs: The patient denies experiencing any wheezing, coughing, or shortness of breath.
Cardiovascular: The patient denies any coughing, palpitations or chest pain.
Breast: The patient denies having any breast enlargement, leakage, pain or swelling of either breast
GI: The patient denies experiencing any sporadic acidity, any gastrointestinal discomfort, or vomiting
Male/female genital: The patient denies any discharge from the penis. The patient denies a history of sexually transmitted infections. The patient denies having a history of erectile dysfunction. The patient denies no history of testicular pain, swelling, or lumps.
GU: The patient denies no pain or discomfort during urination. The patient denies urinary frequency, urgency or leakages. The patient denies any recent changes in urinary stream
Neuro: The patient reports no weakness, numbness, or tingling in any part of the body. The patient denies any history of seizures or convulsions. The patient denies no difficulty with speech or understanding language. The patient denies any history of loss of consciousness, memory loss, or confusion.
Musculoskeletal: The patient denies no joint pain or stiffness. The patient admits to a history of broken arm. The patient reports no muscle weakness or atrophy. The patient denies any difficulty with mobility or range of motion. The patient denies a history of back pain or spinal cord injuries.
Activity & Exercise: The patient admits that neither everyday tasks or exercise regimens present any challenges. The patient admits to exercise constantly, participating in both strength- and aerobic-training exercises. The patient admits that neither his workout routine or his ability to move about have changed recently. The patient denies having ever experienced chronic weakness or weariness.
Psychosocial: The patient admits having obsessive-compulsive symptoms, such as intrusive thoughts, repetitive actions, and severe anxiety. The patient admits devoting a sizable amount of time to obsessive activities, such as hand washing.
Derm: The patient denies having any rashes, lesions, or skin discoloration. The patient denies any itching, burning, or pain on the skin. The patient denies a history of skin cancer or other skin conditions. The patient denies any history of excessive dryness or oiliness of the skin. The patient admits to using sunscreen regularly and avoiding prolonged sun exposure.
Nutrition: The patient admits to having a good appetite and no difficulty with chewing or swallowing. The patient admits a history of egg allergies. The patient admits to eating a balanced diet with a variety of fruits, vegetables, grains, and proteins. The patient denies any significant weight gain or loss in recent months. The patient denies any history of eating disorders or gastrointestinal issues related to diet.
Sleep/Rest: The patient denies having difficulty falling asleep or staying asleep at night. The patient admits to sleeping an average of 8-9 hours per night. The patient denies any history of snoring or sleep apnea. The patient denies any significant daytime fatigue or sleepiness. The patient denies any recent changes in sleep habits or environment.
LMP: Not applicable to this patient.
STI Hx: The patient denies a history of sexually transmitted infections. The patient denies any recent unprotected sexual encounters or high-risk sexual behaviors. The patient admits being in a monogamous sexual relationship with a partner who has also been tested negative for STIs. The patient admitted to using condoms consistently and correctly during sexual activity.
Physical Exam
BP____90/60 mmHg measured while patient was seated____TPR__97.2F taken orally___ HR: __80___ RR: _20___Ht. _6’2____ Wt. 70 kg BMI ( percentile) _19.8 kg/m2 (15%, Healthy weight) Pain: No pain report at the moment
General: The patient seems to be well-fed and not in immediate danger. They are attentive to time, place, and person-oriented. There are no tremors or other physical anomalies present.
HEENT: Head: Normocephalic, trauma-free, and devoid of any palpable lumps or soreness. There are no alopecia-prone spots and an even dispersion of hair. Eyes: The pink, moist conjunctivae are visible. White and free of icteric clerae. The pupils are equidistant, rounded, and light-responsive. Both eyes' visual acuity is 20/20. Nystagmus and ptosis are not present. Ears: There is no irritation or discharge in the external ear canal, which is clear. Tympanic membranes are pearly gray in color and are free of any fluid, perforations, or protrusion. Hearing is unharmed. Nose: The nasal mucosa is pink and wet. There is no indication of a septal misalignment, polyps, or effusion. The sinuses are not sensitive. Throat: There is no tonsillar hypertrophy or exudate, and the oropharynx is clean. The soft palate elevates symmetrically, and the uvula is median. Erythema or edema are not present.
Neck: The neck has a wide range of motion and is flexible. There are no apparent tumors, thyromegaly, or cervical lymphadenopathy.
Pulmonary: Auscultation of both lungs reveals no abnormalities. No rhonchi, crackles, or wheezing are audible.
Cardiovascular: There are no murmurs, gallops, or rubs; the heart sounds are regular. There is no jugular venous distension or peripheral edema present.
Breast: There are no visible tumors, swellings, or asymmetry in the patient's chest, which is symmetrical. The nipples are evenly spaced and exhibit neither discharge or protrusion. Skin retraction or dimpling are not visible. The breast tissue is smooth and soft to the touch, devoid of any lumps, nodules, or discomfort. Nipple discharge or skin changes are not evident. The areola is a typical size and hue.
GI: The abdominal wall is soft and nontender, there are no masses, hepatosplenomegaly, rebound or guarding. All four quadrants contain bowel noises.
Male/female genital: There are no signs of infections, erythema, or discharge on penis and the penis is circumcised. The scrotum is lowered and free of lumps or edema. There is no perceptible discomfort or bulk in the testes, and their size and consistency are typical. The epididymis is non-nodular and non-tender. There are no lymph nodes that can be felt when the inguinal region is examined.
GU: There was no evidence of blood in urine, cloudy urine or foul-smelling urine. There was no report of urinary leakage, incontinence, or frequency.
Neuro: The II–XII cranial nerves remain unharmed. All extremities have a 5/5 strength rating.
Reflexes are normal. There are no visible cerebellar symptoms or sensory impairments.
Musculoskeletal: There are no visible joint malformations or motion restriction. All extremities have a 5/5 strength rating.
Derm: The skin is clean, right ethnicity, there are no wounds, lesions, or rashes on the skin.
Psychosocial: The mental state examination reveals no anomalies. The patient describes OCD-like symptoms, such as intrusive thoughts and repetitive actions. They are receptive to treatment and agreeable. No suicidal thoughts or homicidal thoughts detected.
Misc. N/A
Mental Status Exam
Appearance: The patient comes across as stressed and preoccupied. They look good and are dressed appropriately.
Behavior: The patient engages in compulsive actions like constant hand washing and scanning the room.
Speech: The patient's speech is clear and coherent when he describes his obsessions and compulsions in detail.
Mood: The patient appears anxious and distressed due to his uncontrollable obsessions and compulsions.
Affect: The patient's affect is constricted due to his preoccupation with his symptoms.
Thought Content: The patient's thoughts are preoccupied with his fear of contamination and germs.
Thought Process: The patient's thought process is repetitive and circular due to his preoccupation with his symptoms.
Cognition/Intelligence: The patient answers questions correctly and seems to be of normal intellect.
Clinical Insight: Even if the patient is cognizant that his obsessions and compulsions are unreasonable, he feels forced to act on them.
Clinical Judgment: The patient's judgment is impaired by his obsessions and compulsions, which he claims interferes with his ability to function in daily life.
Significant Data/Contributing Dx/Labs/Misc.
Plan:
Yale-Brown Obsessive-Compulsive Scale (Y-BOCS)
The Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) measures the frequency and
severity of obsessions and compulsions and produces an overall score that can assist inform
treatment choices (Houghton & Sibrava, 2019). It is a self-report tool used to gauge the severity
of OCD symptoms. The patient's Y-BOCS score of 29.5 was considered suggestive of severe
OCD symptoms with significant interference in daily functioning.
According to the patient's symptoms, Diagnostic and Statistical Manual of Mental
Disorders (DSM-5) criteria were applied. The main diagnostic instrument used by mental health
practitioners to identify mental disorders, including OCD, is the DSM-5 (Abramowitz et al.,
2018). The patient has obsessions and compulsions that are time-consuming, upsetting, and
interfere with daily functioning, as defined by the DSM-5 criteria.
Differential Diagnoses
1. Obsessive-compulsive disorder (ICD-10 F42 and DSM-5 300.3)
2. Generalized anxiety disorder (ICD-10 F41.1 and DSM-5 300.02)
Generalized anxiety disorder is a condition marked by excessive concern and anxiety about regular occurrences (Newman & Llera, 2019). Obsessions and compulsions are also possible in people with GAD, but they are typically linked to their fears and anxieties.
Principal Diagnoses
1. Obsessive-compulsive disorder (ICD-10 F42 and DSM-5 300.3)
Obsessive-Compulsive Disorder, also known as OCD, is a mental health condition marked by intrusive, unwelcome thoughts or images (obsessions), which trigger ritualistic, repetitive activities (compulsions), which are meant to counteract or lessen the anxiety and discomfort brought on by the obsessions (Storch et al., 2022). OCD can be a crippling condition that affects daily living and quality of life. OCD is often treated with a mix of medication and psychotherapy, including cognitive-behavioral therapy (CBT) or exposure and response prevention (ERP) therapy, which can assist people in learning to control their symptoms and enhance their general wellbeing.
Plan:
Clomipramine 25 mg PO QD in the morning was the pharmaceutical regimen recommended for the patient, and it was to be taken for two weeks. A supply of 30 clomipramine oral capsules, each containing 50 mg, costs around $25.
Diagnosis #1 OCD (Obsessive-Compulsive Disorder)
Diagnostic Testing/Screening: Yale-Brown Obsessive Compulsive Scale (Y-BOCS) score of 29.5.
Pharmacological Treatment:
Name: Clomipramine
Dosage: 25 mg
Route: Taken orally
Frequency: Once a day in the morning
Estimated Cost: A supply of 30 clomipramine oral capsules, each containing 50 mg, costs around $25.
Non-Pharmacological Treatment: Cognitive behavioral therapy.
Patient/Family Education:
1. Engage in relaxation exercises like yoga, meditation, or deep breathing.
2. Take prescription drugs exactly as your doctor has instructed.
3. Regularly attend psychotherapy sessions to develop coping and management skills.
4. Reject and refute unfavorable assumptions about obsessions and compulsions.
5. Keep a journal to record compulsive thoughts and activities.
6. Establish reasonable objectives to combat OCD symptoms.
Referrals: Psychotherapist for CBT
Follow-up: 1 week to assess if he has noticed any improvements in his life.
Anticipatory Guidance:
1. Concentrate on enjoyable pursuits and interests to block out OCD symptoms.
2. Exercise self-care and self-compassion.
3. Maintain a healthy diet and engage in regular exercise.
4. Avoid using drugs or alcohol because these can make OCD symptoms worse.
5. Establish a daily regimen to bring structure and regularity into your life.
6. Ask dependable family and friends for social support.
Signature (with appropriate credentials): __________________________________________
Cite current evidenced based guideline(s) used to guide care (Mandatory)_______________
References
Abramowitz, J. S., Blakey, S. M., Reuman, L., Leonard, R. C., & Kellermann, J. (2018). Obsessive-Compulsive Disorder. In S. G. Hofmann (Ed.), Essentials of Treating Anxiety and Depression (pp. 223-245). American Psychological Association. https://doi.org/10.1037/0000100-012
Houghton, D. C., & Sibrava, N. J. (2019). Cognitive-behavioral therapy for obsessive-compulsive disorder. Psychiatric Clinics, 42(4), 623-638. https://doi.org/10.1016/j.psc.2019.07.009
Newman, M. G., & Llera, S. J. (2019). A novel theory of experiential avoidance in generalized anxiety disorder: A review and synthesis of research supporting a contrast avoidance model of worry. Clinical Psychology Review, 72, 101756. https://doi.org/10.1016/j.cpr.2019.101756
Storch, E. A., McKay, D., Goodman, W. K., & Reid, J. M. (2022). Cognitive behavioral therapy for obsessive-compulsive disorder: A review of evidence-based treatment options . Journal of Obsessive-Compulsive and Related Disorders, 32, 100644. https://doi.org/10.1016/j.jocrd.2022.100644
DEA#: 101010101 STU Clinic LIC# 10000000
Tel: (000) 555-1234 FAX: (000) 555-12222
Patient Name: (Initials)________________R.S.______________ Age _____19 years______
Date: ________21/03/2023_______
RX ________ Clomipramine ______________________________
SIG: Clomipramine 25 mg PO QD in the morning to be taken for two weeks. A supply of 30 clomipramine oral capsules (50 mg) costs around $25.
Dispense: ____14_______ Refill: _____0____________
No Substitution
Signature: ____________________________________________________________
Rev. 2272022 LM
