Assignment 2: Comprehensive Psychiatric Evaluation and Patient Case Presentation
Comprehensive psychiatric evaluations are a way to reflect on your practicum experiences and connect the experiences to the learning you gain from your weekly Learning Resources. Comprehensive notes, such as the ones required in this practicum course, are often used in clinical settings to document patient care.
For this Assignment, you will document information about a patient that you examined during the last 5 weeks, using the Comprehensive Psychiatric Evaluation Template provided. You will then use this note to develop and record a case presentation for this patient.
- Select a patient that you examined during the last 5 weeks. Review prior resources on the disorder this patient has. Also review the Kaltura Media Uploader resource in the left-hand navigation of the classroom for help creating your self-recorded Kaltura video.
- 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. All psychiatric evaluations must be signed, and each page must be initialed by your Preceptor. When you submit your document, you should include the complete Comprehensive Psychiatric Evaluation as a Word document, as well as a PDF/images of each page that is initialed and signed by your Preceptor. You must submit your document using SafeAssign. Please Note: Electronic signatures are not accepted. If both files are not received by the due date, Faculty will deduct points per the Walden Late Policies.
- Develop a video case presentation, based on your progress note of this patient, 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.
- Include at least five (5) scholarly resources to support your assessment and diagnostic reasoning.
- Ensure that you have the appropriate lighting and equipment to record the presentation.
Record yourself presenting the complex case for your clinical patient. In your presentation:
- Dress professionally with a lab coat and present yourself in a professional manner.
- Display your photo ID at the start of the video when you introduce yourself.
- Ensure that you do not include any information that violates the principles of HIPAA (i.e., don’t use the patient’s name or any other identifying information).
- Present the full case. Include 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.
- Report normal diagnostic results as the name of the test and “normal” (rather than specific value). Abnormal results should be reported as a specific value.
Be succinct in your presentation, and do not exceed 8 minutes. Address the following:
- 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?
By Day 7
Submit your Video and Comprehensive Psychiatric Evaluation. You must submit two (2) files for the evaluation, including a Word document and scanned PDF/images of each page that is initialed and signed by your Preceptor.
Submission and Grading Information
To submit your completed Assignment for review and grading, do the following:
- Please save your Assignment using the naming convention “WK5Assign2+last name+first initial.(extension)” as the name.
- Click the Week 5 Assignment 2 Rubric to review the Grading Criteria for the Assignment.
- Click the Week 5 Assignment 2 link. You will also be able to “View Rubric” for grading criteria from this area.
- Next, from the Attach File area, click on the Browse My Computer button. Find the document you saved as “WK5Assgn2+last name+first initial.(extension)” and click Open.
- If applicable: From the Plagiarism Tools area, click the checkbox for I agree to submit my paper(s) to the Global Reference Database.
- Click on the Submit button to complete your submission.
NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Exemplar
(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.)
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.
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. This section contains the symptoms that is bringing the patient into your office. 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 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?
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).
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 diagnosis selection. 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!), 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.).
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.
NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template
CC (chief complaint):
Past Psychiatric History:
- General Statement:
- Caregivers (if applicable):
- Medication trials:
- Psychotherapy or Previous Psychiatric Diagnosis:
Substance Current Use and History:
Family Psychiatric/Substance Use History:
- Current Medications:
- Reproductive Hx:
Physical exam: if applicable
Mental Status Examination:
NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template
CC (“feeling depressed”):
HPI: JJ is a 36-year-old Asian American male who reports to the clinic for an initial visit with a chief complaint of depression. The patient notes that he has been feeling that way for six months now. He also reports diminished sleep which started 5 months ago and has gradually worsened since then. He also cites lack of sleep as a contributing factor to low concentration and efficiency at his workplace, which has become notable by his seniors. The patient also notes that he has become disinterested in social events and has since stopped going to church. Instead, he prefers to be alone. The patient reports using Zoloft 50 mg PO qDay, which he notes to have stopped working about a month ago.
Past Psychiatric History:
- General Statement: The patient has had a previous counseling session for depression after having lost her wife a year and a half ago
- Caregivers (if applicable):
- Hospitalizations: The patient has not been hospitalized before for any mental disorders. The patient also denies having any history of suicidal ideations or self-harm behaviors.
- Medication trials: The patient has had a previous prescription of Zoloft 50 mg PO qDay, which he notes to have stopped working about two months ago.
- Psychotherapy or Previous Psychiatric Diagnosis: The patient has previously tried to engage in suggested psychotherapy, including the use of meditation but he notes that he has never been patient enough to consistently practice the approach.
Substance Current Use and History: The patient states that he smokes cigarettes approximately three to four sticks every day, and his habit has since worsened since he started feeling depressed. He used to drink but stopped three years ago and has never engaged in alcohol since then. He notes that he has never tried enrolling in any smoking cessation program but he desires to quit since he understands the harmful effects smoking has on his health.
Family Psychiatric/Substance Use History: The patient’s grandfather used to drink but had great tolerance to alcohol as noted. The parents were avid Christians who never encouraged the use of any substance. The patient’s eldest brother smokes cigarettes (between 3 t 5 sticks daily) and also drinks alcohol mainly during the weekend. The family has never had any history of suicides or psychiatric illness.
Psychosocial History: The patient was born in the U.S after his parents and grandparents migrated from China for employment opportunities forty years ago. The parents have since then become full citizens, granting JJ citizenship by birth. The patient was raised by his parents who were always there for him, after which, he married a White, who unfortunately died after a long struggle with cancer just over a year ago.
The patient only has one elder brother, with both parents still being alive. Currently, the patient is widowed and lives alone. He has not been interested in looking for a partner since his wife died. He doesn’t have any children yet.
JJ graduated three years ago with an undergraduate degree in civil engineering and currently works with a construction company as a resident engineer and a project manager. However, recently his performance and concentration at work have been gradually reducing. Some of his hobbies are biking, hiking, and reading. Before his wife died, they used to go out and have fun with friends at least every weekend, but since then his social habits have greatly changed.
Recently, he had a minor accident, where he bumped into a car but managed to solve the issue amicably. He notes that he cannot explain what happened exactly. Otherwise, he had not had any recent engagements with law enforcement. JJ also reports he has never had any noteworthy trauma during his childhood, noting that he had a fairly normal upbringing.
Violence Hx: the patient reported no history of violence.
Medical History: The patient has previously had an appendectomy when he was 20 years.
- Current Medications: Zoloft 50 mg PO qDay
- Allergies: No food, drug, or seasonal allergies
- Reproductive Hx: The patient notes his sexual orientation as straight, but has not engaged in any form of sexual intercourse within the past 2 months.
- GENERAL: Weight loss of 6 pounds in two months, no fever, chills, or weakness reported. The patient however appears to be lethargic.
- HEENT: No visual loss, blurred vision, double vision, or yellow sclerae. No hearing loss, sneezing, congestion, runny nose, or sore throat, Voice sounds scratchy.
- CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema were noted.
- RESPIRATORY: No sputum, cough, wheezing sound, or shortness of breath.
- NEUROLOGICAL: Mild headache, no dizziness or syncope,
Physical exam: N/A
Diagnostic results: The diagnostic test needed for this to assess whether the patient has depression is a Montgomery- Asberg Depression Rating Scale (MADRS). According to Hengartner et al. (2020), MADRS is considered a gold standard for diagnosing patients suspected of having depression. MADRS helps to assess whether a patient has depression and the severity of the disease.
Mental Status Examination: The patient is a 36-year-old Asian American male. He appears to be well dressed and constituted during the exams. He does not consistently maintain eye contact during the exams. He answers all questions appropriately and he is well oriented to both time, place, event. and person. He denies having any suicidal ideation, self-harm, delusional, or paranoid thoughts.
Based on the assessment of the patient, the three differentials include;
- Major Depressive disorder (primary)
- Bipolar Disorder
- Adjustment disorder with depressed mood
- Borderline personality disorder
The primary diagnosis for the selected case is major depressive disorder. The symptoms presented in the case appear to be synonymous with the DSM IV manual on mental disorders. According to the American Psychiatric Association. (2013). DSM-IV manual, major depressive episode occurs when an individual has 5 or more depressive symptoms for more than two weeks. Some of the symptoms JJ portrays that links to depression include; depressed mood, diminished interest in social activities, insomnia, diminished ability to concentrate, and feeling fatigued. Due to these factors, major depressive disorder was considered as the primary diagnosis
The second diagnosis is bipolar disorder. Bipolar disorder is a condition characterized by manic episodes and low depressive episodes (Vieta et al., 2018). However, given that the patient did not report or show any signs of manic episodes, then it is eliminated as the primary diagnosis. Adjustment disorder with depressed mood is another possible diagnosis that could be linked to the patient having lost his wife, and also matches with the onset of the depression. The symptoms presented by JJ also meet the DSM-IV criteria of adjustment disorder with depressed mood. The last diagnosis is borderline personality disorder, which is associated with emotional instability and can make one have bouts of depression (Scott et al., 2017). However, the patient does not meet the criteria of the disorder as per the DSM-IV manual.
The case presents an Asian American patient with symptoms aligning with those of major depressive disorder. Based on the presented facts, I agree with my preceptor’s analysis of the case. The DSM-IV manual highlights some of the aspects that qualify one to be diagnosed with major depressive disorder. Some of these aspects include having a depressed mood, diminished interest in social events, insomnia, reduced ability to concentrate, and feeling fatigued (American Psychiatric Association., 2013), which makes me agree with the diagnosis. Results of the MADRS will further clarify whether the patient has depression and the severity of the disorder. From this case, I learned that depression can impair one’s optimal functionality and without guided evidence-based interventions, it is difficult for a patient to return to optimal functioning. I would
Some of the ethical considerations involved in this case include weighing the benefits of therapeutic approaches in conformance with ethical principles of maleficence and beneficence. As noted by Wang et al. (2018), some of the anti-depressants that can be used to assist the patient have serious side effects. Therefore the care professional should weigh the pros and cons and alternative interventions before prescribing. Following the same ethical principle, the patient should be encouraged to have gene testing, specifically for the CYP2D6 allele that has an impact on drug metabolism. According to Milosavljević et al. (2020), variation in the CYP2D6 allele has an impact on the metabolism of antidepressants and antipsychotics. Other studies noting that Asians have a higher prevalence of the mutation, thus having an impact on antidepressant prescriptions (Bagheri et al., 2015)
The health promotion initiatives that will be recommended to the patient include health promotion on smoking cessation, including identification of resources that will help the patient quit. Another health promotion opportunity is o physical exercises which are known to have a therapeutic effect that can assist patients with depression to have improvements in terms of coping.
American Psychiatric Association. (2013). Dissociative disorders. In Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author. doi:10.1176/appi.books.9780890425596.dsm08
Bagheri, A., Kamalidehghan, B., Haghshenas, M., Azadfar, P., Akbari, L., Sangtarash, M. H., Vejdandoust, F., Ahmadipour, F., Meng, G. Y., & Houshmand, M. (2015). Prevalence of the CYP2D6*10 (C100T), *4 (G1846A), and *14 (G1758A) alleles among Iranians of different ethnicities. Drug design, development, and therapy, 9, 2627–2634. https://doi.org/10.2147/DDDT.S79709
Hengartner, M. P., Jakobsen, J. C., Sørensen, A., & Plöderl, M. (2020). Efficacy of new-generation antidepressants assessed with the Montgomery-Asberg Depression Rating Scale, the gold standard clinician rating scale: A meta-analysis of randomized placebo-controlled trials. PLoS One, 15(2), e0229381. https://doi.org/10.1371/journal.pone.0229381
Milosavljević, F., Bukvić, N., Pavlović, Z., Miljević, Č., Pešić, V., Molden, E., … & Jukić, M. M. (2020). Association of CYP2C19 and CYP2D6 poor and intermediate metabolizer status with antidepressant and antipsychotic exposure: a systematic review and meta-analysis. JAMA Psychiatry. doi:10.1001/jamapsychiatry.2020.3643
Scott, L. N., Wright, A. G., Beeney, J. E., Lazarus, S. A., Pilkonis, P. A., & Stepp, S. D. (2017). Borderline personality disorder symptoms and aggression: A within-person process model. Journal of Abnormal Psychology, 126(4), 429.
Vieta, E., Salagre, E., Grande, I., Carvalho, A. F., Fernandes, B. S., Berk, M., & Suppes, T. (2018). Early intervention in bipolar disorder. American Journal of Psychiatry, 175(5), 411-426. https://doi.org/10.1176/appi.ajp.2017.17090972
Wang, S. M., Han, C., Bahk, W. M., Lee, S. J., Patkar, A. A., Masand, P. S., & Pae, C. U. (2018). Addressing the side effects of contemporary antidepressant drugs: a comprehensive review. Chonnam Medical Journal, 54(2), 101-112. https://doi.org/10.4068/cmj.2018.54.2.101