COMPREHENSIVE PSYCHIATRIC EVALUATION AND PATIENT CASE PRESENTATION, DOCUMENTATION
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6635PRACComprehensivePsychiatricEvaluationTemplaterev12.2022.doc
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NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template
Week (week #4): (Assessing and Diagnosing Patients with Anxiety Disorders, PTSD and OCD)
Student Name
College of Nursing-PMHNP, Walden University
NRNP 6635: Psychopathology and Diagnostic Reasoning
Faculty Name
Assignment Due Date
Subjective:
CC (chief complaint): “I just really needed to sit and talk”
HPI: Mrs. Weidre is a 53-year-old female who presents with complaints of being stuck in her house and she does not like it. She has been brought in by her husband due to difficulty leaving the house. The patient reports having difficulty leaving the house all the time. Sh states she goes out once or twice, particularly Tuesdays and Saturdays when her husband is at home as he accompanies her. She reports taking short walks around the street before “losing breath.” She states can take longer walks as she “just can’t breathe” if she is out any longer. She states she is just frightened and really scared whenever she is out. She states that she closed her eyes and her husband had to turn on music all the way as they drove to the clininc as she was frightened. She states she does not like interacting with people, although she can be around people. Mrs. Weidre states he is afraid of death, and is what frightens her. The client reports that ever since her mother died, she is afraid of dying to the extent that she cannot go see her grandson who was born the last week because she cannot leave the house.
Past Psychiatric History:
· General Statement: Lives with her husband in Memphis, TN and denies any past psychiatric illness and family history of mental illness.
· Caregivers (if applicable): Lives with her husband
· Hospitalizations: Denies past hospitalizations.
· Medication trials: Denies medication trials
· Psychotherapy or Previous Psychiatric Diagnosis: Denies past psychotherapy or past psychiatric diagnosis. No substance hx for patient. No previous psychiatric treatment.
Substance Current Use and History: No substance hx for patient. Pt. states she has one glass red wine with dinner.
Family Psychiatric/Substance Use History: Mother with hx of generalized anxiety and was verbally abusive, abused benzodiazepines. No substance hx for patient.
Psychosocial History: Mrs. Weidre was raised by her mother and currently lives with her husband in Colorado. She states she has a brother who lives miles away. Her daughter is her only child and she is now married and lives far away. She has an adminstrateive degree, but she stopped working as she cannot leave the house.
Medical History: Denies any childhood illness or any other illnesss.
· Current Medications: Takes PRN Tylenol, takes OTC Imodium.
· Allergies: Allergicb to Zofran
· Reproductive Hx: Reached menopause at 46years and uses no contraceptive.
ROS:
· GENERAL: Denies losing or gaining weight. No fevers or sweating at night. Reports sleeps 12-13 hrs. Appetite decresed.
· HEENT:Denies dizziness, headache, or ear or eye aches. Denies difficulty swalling of vision problems.
· SKIN: No skin rushes, or bruises
· CARDIOVASCULAR: Denies chest tightness or chest pain.
· RESPIRATORY: Denies cough or wheezing. Reports shortness of breath.
· GASTROINTESTINAL: Denies stomach cramps, vomiting, upset or diarrhea.
· GENITOURINARY: Denies hematuria, signs of urinary frequency, urgency or pain.
· NEUROLOGICAL: Denies ataxia or numbness
· MUSCULOSKELETAL: Denies muscle or joint pain
· HEMATOLOGIC: No signs of bleeding or bruises
· LYMPHATICS: Reports no swollen or painful lymph nodes.
· ENDOCRINOLOGIC: No signs of enlarged or decreased thyroid.
Objective:
Physical exam: if applicable
Diagnostic results:
Vitals: T-99.0 P-102 R 24 BP 156/76 Ht 5’4 Wt 1lbs73
Assessment:
Mental Status Examination: Mrs. Weidre is a 56-year-old female who is brought for psychiratric assessment by her husband. She is well-groomed and oriented to place, time and person. She sppesrs her stated age and occasionally maintains eye contact. Her speech is pressured and spontaneous. She appears confused with delusional thoughts. Normal psychomotor movements. Denies auditory, visual or gustatory hallucinations. Denies suicidal or homicidal ideations. She presents with poor judgement.
Differential Diagnoses:
F43.1 Post-trauamtic Stress Disorder
Post-traumatic stress disorder (PTSD) is a mental health condition that is featured by very frightening, stressful or distressing events. A person with PTSD often relieves their past traumatic epxeeinces through flashbacks or nightmares and may experience fear, feelings of guilt, irritability or isolation (Merians et al., 2023). They may also have sleeping problems and difficulty concentrating. These symptoms often impact the person’s day-to-day life. In this case, Mrs. Mrs. Weidre fears going out from the time her mother passed on. She associates going out with death, a mechanism of relieving the consequences of the traumatic event. She also reports falling shortness of breath and difficulty slepping, which are both consequences of the traumatic event experienced in her life. Therefore, the client meets the criteria for PSTD as the problems she is currently experiencing are tied to a past traumatic event (passing of her mother).
F43.0 Acute Stress Disorder
This disorder presents similar symptoms to PTSD, such as avoidance, intrunsive memories and hyperarousal. It develops within one month of witnessing or experiencing a traumatic event (Byrant, 2017). However, in this client’s case, the symptoms have persisted beyond one month, indicating PTSD.
F19.951 Substance/Medication-induced psychotic disorder, Unspecified
This diagnosis is characterized by the client exhibiting strong delusions and hallucinations associated with physiological or substance dosage effects (Fiorentini et al., 2021). Even the client has a fixed false belief of associatibg going out of the house with death, she does not have any hallucinations. Furthermore, she shows no signs of withdrawal or intoxication. The urine and drug lab tests turned negative.
Reflections: If I were to conduct this interview, I would ensure to create strong rapport with the client to ensure they disclose adequate information to make a diagnosis. For instance, I would ask more of how her mother’s death affected her to date. Communication with the husband as part of therapy would ensure the client’s needs are addressed holistically. One ethical issue is the hospitalization of the PTSD client against their will. If the clinician prioritizes their self-intersts over those of the patient and her family, it poses significant ethical dilemmas. Health promotion can be achieved through organizing and facilitating group therapies to ensure sharing similar experiences and supporting one another throughout the recovery process.
References
Bryant R. A. (2017). Acute stress disorder. Current opinion in psychology, 14, 127–131. https://doi.org/10.1016/j.copsyc.2017.01.005
Fiorentini, A., Cantù, F., Crisanti, C., Cereda, G., Oldani, L., & Brambilla, P. (2021). Substance-Induced Psychoses: An Updated Literature Review. Frontiers in Psychiatry, 12, 694863. https://doi.org/10.3389/fpsyt.2021.694863
Merians, A. N., Spiller, T., Harpaz-Rotem, I., Krystal, J. H., & Pietrzak, R. H. (2023). Post-traumatic Stress Disorder. The Medical Clinics of North America, 107(1), 85–99. https://doi.org/10.1016/j.mcna.2022.04.003
© 2021 Walden University Page 5 of 5
NRNP_PRAC_6635_ComprehensivePsychiatricEvaluationExemplar_rev.4.2022.docx
NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Exemplar
INSTRUCTIONS ON HOW TO USE EXEMPLAR AND TEMPLATE—READ CAREFULLY
If you are struggling with the format or remembering what to include, follow the Comprehensive Psychiatric Evaluation Template AND the Rubric as your guide. It is also helpful to review the rubric in detail in order not to lose points unnecessarily because you missed something required. Below highlights by category are taken directly from the grading rubric for the assignment in Weeks 4–10. After reviewing the full details of the rubric, you can use it as a guide.
In the Subjective section, provide:
· Chief complaint
· History of present illness (HPI)
· Past psychiatric history
· Medication trials and current medications
· Psychotherapy or previous psychiatric diagnosis
· Pertinent substance use, family psychiatric/substance use, social, and medical history
· Allergies
· ROS
· Read rating descriptions to see the grading standards!
In the Objective section, provide:
· Physical exam documentation of systems pertinent to the chief complaint, HPI, and history
· Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses.
· Read rating descriptions to see the grading standards!
In the Assessment section, provide:
· Results of the mental status examination, presented in paragraph form.
· At least three differentials with supporting evidence. List them from top priority to least priority. Compare the DSM-5-TR diagnostic criteria for each differential diagnosis and explain what DSM-5-TR criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case .
· Read rating descriptions to see the grading standards!
Reflect on this case. Include: Discuss what you learned and what you might do differently. Also include in your reflection a discussion related to legal/ethical considerations ( demonstrate critical thinking beyond confidentiality and consent for treatment !), social determinates of health, 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.).
(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.) EXEMPLAR BEGINS HERE
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. First what is bringing the patient to your evaluation. Then, include a PSYCHIATRIC REVIEW OF SYMPTOMS. 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-TR 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.
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 diagnostic impression selection. You will use supporting evidence from the literature to support your rationale. 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!), social determinates of health, 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.).
References (move to begin on next page)
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.
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