Comprehensive Psychiatric Evaluation Note and Patient Case Presentation
Catherine2
NRNP6645PsychotherapyAssessment.docxPsychotherapy, 60 minutes with patient
Patient’s Age: 34 yrs.
Chief complaint: The patient stated, “I am stressed on my job and in my personal life”.
Vitals
Height: 5’6”
Weight: 158 lbs.
B/P: 136/74
Temperature: 97.3
Pulse: 88
Respiratory rate: 18
O2 Saturation: 97%
Pain: Denied any pain presently
Diagnoses
•Major depressive disorder.
Allergies
Drug allergies
Patient has no known drug allergies
Food allergies
No food allergies
Environmental allergies
No environmental allergies
Medications:
Escitalopram Oxalate (Lexapro) 5 MG Oral Tablet. Take 1 tablet (5 mg) by mouth daily
Escitalopram Oxalate (Lexapro) 10 MG Oral Tablet. Take 1 tablet (10 mg) by mouth daily
Smoking status
Non-smoker 01/25/2021
Gender identity
Female
Sexual orientation
Straight or heterosexual
Social history:
Patient completed high school and is trying to get her degree in BA Business. She has two children and is not sexually active at the moment She works as an oncology financial navigator for ANOVA Hospital
Past medical history
Family health history:
No one clinically diagnosed with mental illness in the family
Social history:
Patient completed high school and is trying to get her degree in BA Business. She has two children and is not sexually active at the moment She works as an oncology financial navigator for ANOVA Hospital
Developmental history:
Patient grew up with both parents at the beginning. She reports that her parents separated when she was 8 years. She reports that her father was great, but her mother was physically and emotionally abusive when she was a child. She is trying to have a positive relationship with her mother but feels that her mother's feelings are superficial. Her father is a great source for support
Subjective
The patient stated that she was stressed out on the job and in her personal life.
Objective
The patient is alert and oriented x 4, to person, place, time and situation. She was engaging and her mood was appropriate. She expressed and shared her emotions. She stated that she is stressed at and in her personal life.
Objective Continues
General appearance: Appropriate
Attitude: Good
Behavior: normal
Speech: Soft
Mood: Normal
Affect: Normal
Thought Process: Good
Thought Content: Good
perceptions: Fair
insight: Good
judgment: Fair
cognition: Good
Memory: Intact
Assessment
The patient shared that she was stressed. She had some medical challenges that she is currently under a doctor's care for. The patient stated that she has an inflammation around her ribs that she was told was the result of stress.
The patient shared that she was happy that her son was accepted into his aftercare program and was doing well that the wanted him to join their full martial arts program. However, the patient stated that she cannot afford the full program. She asked her son's father for financial assistance and he reported he could only contribute $100. The cost of the program per the patient is $600.00 a month which she states that she cannot afford. Besides the cost, the patient stated that her son is doing well and blossoming in the program.
At school, the patient stated that she learned that someone was hitting on her son. The patient stated that her son did not tell her anything that was happening at school, she learned from the teacher.
Self-care / stress reducing interventions was discussed with the patient. The patient stated that she would try to incorporate it. However, small deep breathing, meditation, timeout interventions were discussed that can be incorporated daily to help reduce stress.
Plan
The patient will incorporate small selfcare stress reducing interventions in her daily activities.
The patient will follow up with her medical doctor for medical interventions.
The patient will continue to discuss her feelings, emotions and what self-care interventions she utilized.
The patient will continue to do well mentally. She will continue to take her medication as prescribed and note any adverse side effects.
To follow up in 2-4 weeks.
To call 911 if feeling suicidal and/or homicidal ideation.
