Assignment: Comprehensive Psychiatric Evaluation
Assignment: Comprehensive Psychiatric Evaluation
For this Assignment, you will document information about a patient that you examined during the last 3 weeks, using the Comprehensive Psychiatric Evaluation Template provided. You will then use this note to develop and record a case presentation for this patient.
To Prepare
- Review this week’s Learning Resources and consider the insights they provide.
- Select a patient that you examined during the last 3 weeks who presented with a disorder for which you have not already conducted an evaluation in Weeks 3 or 6. (For instance, if you selected a patient with OCD in Week 6, you must choose a patient with another type of disorder for this week.) Conduct a Comprehensive Psychiatric Evaluation on this patient using the template provided in the Learning Resources. There is also a completed exemplar document in the Learning Resources so that you can see an example of the types of information a completed evaluation document should contain
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- Then, based on your evaluation of this patient, develop a case presentation that includes chief complaint; history of present illness; any pertinent past psychiatric, substance use, medical, social, family history; most recent mental status exam; and current psychiatric diagnosis including differentials that were ruled out.
Subjective:
[elementor-template id="165244"]- What details did the patient provide regarding their personal and medical history?
- What are their symptoms of concern?
- How long have they been experiencing them, and what is the severity?
- How are their symptoms impacting their functioning?
Objective:
- What observations did you make during the interview and review of systems?
Assessment:
- What were your differential diagnoses?
- Provide a minimum of three (3) possible diagnoses.
- List them from highest to lowest priority.
- What was your primary diagnosis, and why?
Reflection notes:
- What would you do differently in a similar patient evaluation?
- Reflect on one social determinant of health according to Healthy People 2030 (you will need to research) as applied to this case in the realm of psychiatry and mental health. As a future advanced provider,
- what are one health promotion activity and one patient education considerations for this patient for improving health disparities and inequities in the realm of psychiatry and mental health? Demonstrate your critical thinking.
- Include at least five (5) scholarly resources to support your assessment and diagnostic reasoning.
CASE INFORMATION BELOW:
CC (chief complaint): “I can’t sleep at night, anxiety and pain in my chest. I keep hearing things”.
HPI:
The client is a 39-year-old white female who is here for an annual psychiatric evaluation. She has had past mental health Major Depressive Disorder, Generalized anxiety disorder (GAD), and schizoaffective disorder. She is currently taking Vraylar, Seroquel, Trazodone, Prazosin, Diazepam, and Propranolol. She currently rates her depression as an 8/10 with symptoms of feeling down, low energy, loss of motivation (LOM), loss of pleasure (LOP), and difficulty concentrating for greater than 4 years. She stated that she can’t concentrate in group settings, is easily distracted. She reports feeling anxious all the time and always worrying. She has racing thoughts, + mood fluctuations, + auditory hallucinations (AH), denies visual hallucinations (VH), and + paranoia (suspicious). No evidence of mania or delusions. She denies any inpatient hospitalization. When her mental health was at its worse, she reported that she couldn’t get out of bed, didn’t wash, and had feelings of helplessness and hopelessness, and worthlessness and that she is an embarrassment to her family. She denies past suicidal attempts. No current or recent SI or HI. No history of self-harm and she has a trauma history of physical, sexual, and emotional abuse. She is unable to go into detail about her trauma. She reports having night terrors and flashbacks. She has a therapist that she sees weekly. No current safety issues. Previous medications she tried included Buspar, Lexapro, Prozac, Paroxetine, Celexa, Zoloft, Effexor, Risperdal, Neurontin, and Abilify she reports were all ineffective.
Columbia suicide scale: 1-no 2-no
Substance Current Use: Denies.
Medical History: HTN, Chronic back, and neck pain (Followed by Cardiologist)
- Current Medications: Norvasc 5mg, Hyzaar 100mg-12.5mg, and Metoprolol 25mg
- Allergies: No known drug allergies (NKDA) and no known food allergies (NKFA).
- Reproductive Hx: 2 SVDs (2011 and 2015)
Family Psychiatric/Substance Use History:
The client denies a past psychiatric history on her maternal and paternal sides of the family. One younger brother with no mental health issues.
Psychosocial History:
The client is a 39-year-old female born in Russia and relocated to New Hampshire at the age of 21. She came to Camden, DE, in 2016. She grew up in a home with both parents, she has one younger brother. She is married and takes care of her husband who is a disabled veteran and 3 children. Her parents recently moved into the home to help take care of her 3 children. Her parents are very supportive. Her relationship with her husband and children is good. Her highest level of education graduated with a bachelor’s degree. She currently does not have any hobbies. She is currently mentally disabled and is financially stable with her disability. She has no past legal history or current issues. Positive history of trauma previously noted and currently no safety issues.
ROS:
- GENERAL: Negative for fever, chills, weight gain/loss, and positive for low energy.
- HEENT: Negative for blurred vision, eye pain, ear pain/discharge, hearing loss, nasal discharge, sneezing, or sore throat.
- SKIN: Negative for rash, discoloration, or bruises.
- CARDIOVASCULAR: Positive for chest pain, and palpitations no edema.
- RESPIRATORY: Negative for sob, cough, sputum, or chest pain that is respiratory-related.
- GASTROINTESTINAL: Negative for nausea, vomiting, epigastric pain, or bowel changes.
- GENITOURINARY: Negative for dysuria, or urinary frequency/urgency.
- NEUROLOGICAL: Negative for headache, dizziness, fatigue, muscle weakness, tingling sensations, and +pain in the neck.
- MUSCULOSKELETAL: Negative for muscle pain, joint stiffness, or joint pain.
- HEMATOLOGIC: Negative for bleeding and bruising.
- LYMPHATICS: Negative for enlarged lymph nodes.
- ENDOCRINOLOGIC: Negative for sweating, cold/heat intolerance, excessive thirst, hunger, or urine production.
Vital Signs: Temp- 98.6; P- 92; R-18; BP-144/88; Ht-5’1; Wt-138lbs
Diagnostic results: There are currently no test results available.
Mental Status Examination:
Female client in her late 30’s. She is AAOx3 but appears anxious. She is well-groomed and cooperative. She is dressed appropriately. She maintains good eye contact during the visit, has normal motor activity, and uses facial expressions appropriately. The self-reported mood is anxious, and the affect is appropriate. Her speech is clear with normal volume and tone, she has a logical and goal-directed thought process. There was no evidence of delusions and is having + auditory hallucinations, denies visual hallucinations, obsessions, or suicidal ideation/thoughts. Her short- and long-term memories are intact, his concentration is fair, and she possesses good judgment.
NEED 3 DIFFERENTIAL DX
PLEASE INCLUDE:
- Subjective: What details did the patient provide regarding their personal and medical history? What are their symptoms of concern? How long have they been experiencing them, and what is the severity? How are their symptoms impacting their functioning?
- Objective: What observations did you make during the interview and review of systems?
- Assessment: What were your differential diagnoses? Provide a minimum of three (3) possible diagnoses. List them from highest to lowest priority. What was your primary diagnosis, and why?
- Reflection notes: What would you do differently in a similar patient evaluation? Reflect on one social determinant of health according to Healthy People 2030 (you will need to research) as applied to this case in the realm of psychiatry and mental health. As a future advanced provider, what are one health promotion activity and one patient education considerations for this patient for improving health disparities and inequities in the realm of psychiatry and mental health? Demonstrate your critical thinking.