Comprehensive Psychiatric Evaluation Assignment

Complete and submit your Comprehensive Psychiatric Evaluation, including your differential diagnosis and critical-thinking process to formulate primary diagnosis.
Incorporate the following into your responses in the template:
Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life?
Objective: What observations did you make during the psychiatric assessment? 

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Assessment: Discuss the patient’s mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses with supporting evidence, listed in order from highest priority to lowest 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.
Reflection notes: What would you do differently with this client if you could conduct the session over? Also include in your reflection a discussion related to legal/ethical considerations (demonstrate 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 Assignment.

Subjective:

CC (chief complaint): “I’m scared to go to rehab.”

HPI: L. P. is a Caucasian woman who is 29 years old and has presented herself for mental examination. At the moment, she is not using any kind of psychotropic medicine. She is being referred for the assessment of a long-term detoxification plan for substance abuse. She discloses that she and her lover use crack cocaine on a regular basis, and that they spend up to one hundred dollars each day on their habit. She reveals that she is terrified of going to rehabilitation because she believes that if she does so, others would learn that she is an addict and view her in a different manner. It was at her lover’s idea that she first tried crack cocaine with the hope that it would make her feel more at ease.  She refuses to acknowledge to being an addict, but she claims to require the drug on a regular basis. As she reminisces about her first time taking crack cocaine, she breaks down in tears. According to her, she and her lover launched a business together nine months ago, which specializes in the development of websites and marketing for businesses. She claims that her lover has used approximately $80,000 of the company’s finances to sustain his drug addiction.  In addition, she acknowledges to consuming alcohol two to three times each week smoking marijuana one to two times each week. She claims to have a card for medical cannabis. After being found guilty of cocaine possession and stealing, she has been placed on two years of probation.

Past Psychiatric History:

• General Statement: The patient is presently being cared for at a detoxification center.
• Caregivers (if applicable): N/A

·         Hospitalizations: Unknown.

• Medication trials:
• Psychotherapy or Previous Psychiatric Diagnosis: Unknown

Substance Current Use and History: drinks alcohol 2-3 times weekly. Inhales crack cocaine daily. Smokes marijuana 2 times weekly.

Family Psychiatric/Substance Use History: brother has a history of opioid use. Mother has a history of anxiety and has used benzodiazepine in the past.

Psychosocial History: Patient has a daughter and resides in West Palm Beach, Florida at this time. She shares a home with her lover, with whom they are co-owners of a busines.  She has a record of arrests in the past for stealing and possessing illegal drugs. She is presently on a probationary period of two years with random drug testing. She reports being sexually abused when she was five years old.

Legal History: Previous convictions for possessing illegal drugs and stealing. Presently serving a two-year probation period with obligatory random drug testing. Comprehensive Psychiatric Evaluation Assignment

Medical History: Hepatitis C.

 

·         Current Medications: Not provided.

• Allergies: Amoxicillin
• Reproductive Hx: Has a daughter

ROS:

GENERAL: Reports insomnia and reduced appetite. Denies fever, chills, or fatigue.

HEENT: Eyes: Denies eye problems or visual changes. Ears, Nose, Throat: Denies changes in hearing, sore throat, difficulty swallowing, nasal congestion, or runny nose.

SKIN: Denies itching or rash

CARDIOVASCULAR: Denies chest pain, palpitations or edema.

RESPIRATORY: Denies shortness of breath, cough, or wheeze.

GASTROINTESTINAL: Reports anorexia. Denies abdominal pain, nausea, vomiting, or diarrhea.

GENITOURINARY: Denies polyuria, dysuria, or  hesitancy

NEUROLOGICAL: Denies headache, dizziness, numbness, or tingling

MUSCULOSKELETAL: Denies muscle, back pain, or joint pain HEMATOLOGIC: Denies history of anemia or bleeding.

LYMPHATICS: Denies  history of splenectomy or enlarged nodes.

ENDOCRINOLOGIC: Denies cold or heat intolerance, or excessive sweating

 

Objective:

Physical exam:

Vital signs: T- 99.8 P- 101 R 20 178/94 Ht 5’6 Wt 140lbs

Diagnostic results: Comprehensive Psychiatric Evaluation Assignment

Assessment:

Mental Status Examination: This is a Caucasian woman who is 29 years old, but she seems much older. She is well-dressed, but has unkempt hair. Displays depressed mood with fairly guarded and constricted affect. Displays psychomotor agitation. She is alert and oriented, with discontinuous eye contact. Hesitant and brief speech noted.  Exhibits good judgment and good memory. Has impaired insight into her health status. Has disturbed and somewhat illogical thought process. No suicidal ideation, delusions, or hallucinations.

Differential Diagnoses:

Substance Use Disorder: This is a complicated mental illness that is defined by the use of a drug without control despite the fact that it has adverse consequences. Individuals who suffer from substance use disorder tend to place an excessive amount of importance on their drug of choice, to the extent that it interferes with their ability to carry out even the most basic of tasks. Co-occurring illnesses of mental health, such as depression, are common in those who struggle with substance use disorder (Kalin, 2020). An individual’s first foray into substance abuse may have been an experimental usage of a recreational substance while in the company of others; thereafter, the frequency of the individual’s drug use may have increased. For some people, especially those who abuse opioids, the first time they try drugs is after being exposed to medicines that they were prescribed for them, or after getting pills from a person who was prescribed the medicine. The DSM-5 Criteria for substance use disorder encompasses a variety of symptoms, some of which include consuming the substance in increasing quantities, having cravings and desires to use the substance, and not being able to do day-to-day responsibilities due of substance use.

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Major Depressive Disorder, Severe, without Psychosis: This is a mental illness that affects one’s emotions, thoughts, and actions. It brings on feelings of melancholy as well as a diminished capacity to take pleasure in activities that were formerly favorites (Belujon & Grace, 2017)Comprehensive Psychiatric Evaluation Assignment. For a person to be given a diagnosis of major depressive disorder, they need to exhibit at least five symptoms over the course of the same two-week period, with at least one of those symptoms being either a low mood or a decreased interest. The person must experience distress or impairment in social, occupational, or other crucial fields of human endeavor as a direct result of the symptoms that meet the criteria for clinical relevance. In addition, the symptoms should not be the consequence of drug addiction or any other kind of medical disease.

Drug Induced Mood Disorder: A change in how someone thinks, feels, or acts that is triggered by taking or quitting the use of a substance is known as a drug-induced mood disorder. Both legal and illicit drugs may make a person feel depressed, give them an excessive amount of energy, and make it difficult for them to manage their behavior (Revadigar & Gupta, 2021). The fact that the symptoms only last for a limited amount of time is the characteristic that makes it most straightforward to separate an independent mood illness from one that is triggered by drug use. When a person stops being very intoxicated or going through acute withdrawal, the symptoms of a drug-induced mood disorder will go away.

Reflections: One thing I would do differently with this patient if I had a second chance is do further diagnostic tests to exclude the possibility of a differential diagnosis from the picture. The significance of keeping a close eye on the patient during the evaluation was one of the important takeaways from the process.

Individuals with substance use disorder are generally disregarded by society because of their drug abuse, and this stigma is often perpetuated. Stigmatization has been shown to have a direct impact on the course of care, encompassing preventive, therapeutic, and rehabilitative interventions for people with substance use disorders (Wogen & Restrepo, 2020). This vulnerable demographic is, as a direct consequence of the stigma, susceptible to societal judgment, humiliation, ill-treatment, and even unwillingness to offer them psychiatric help. The majority of the time, the ill-treatment comes straight from the professionals who are intended to aid the patient. It is essential for the PMHNP to comprehend and triumph over the ethical task of creating an empathetic, patient-centered treatment strategy while working with individuals suffering from substance use disorders (Wogen & Restrepo, 2020)Comprehensive Psychiatric Evaluation Assignment.

References

American Psychiatric Association. (2013). DSM 5 diagnostic and statistical manual of mental disorders. In DSM 5 Diagnostic and statistical manual of mental disorders (pp. 947-p).

Belujon, P., & Grace, A. A. (2017). Dopamine system dysregulation in major depressive disorders. International Journal of Neuropsychopharmacology, 20(12), 1036-1046. https://doi.org/10.1093/ijnp/pyx056

Kalin, N. H. (2020). Substance use disorders and addiction: Mechanisms, trends, and treatment implications. American Journal of Psychiatry, 177(11), 1015-1018. https://doi.org/10.1176/appi.ajp.2020.20091382

Revadigar, N. & Gupta, V. (2021). Substance induced mood disorders. In Statpearls [Internet]. Treasure Island. https://www.ncbi.nlm.nih.gov/books/NBK555887/

Wogen, J., & Restrepo, M. T. (2020). Human rights, stigma, and substance use. Health and human rights, 22(1), 51. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7348456/

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: Comprehensive Psychiatric Evaluation Assignment

• 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: Comprehensive Psychiatric Evaluation Assignment

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)Comprehensive Psychiatric Evaluation Assignment

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)Comprehensive Psychiatric Evaluation Assignment

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 Comprehensive Psychiatric Evaluation Assignment.

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).

Assessment

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.)Comprehensive Psychiatric Evaluation Assignment., 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? Comprehensive Psychiatric Evaluation Assignment

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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 Comprehensive Psychiatric Evaluation Assignment