Psychiatric Comprehensive Evaluation Assignment
CC: “I have sleeping for less than 2 hours a night and I find myself overly energetic. My sister thinks I am crazy because the other day I had an altercation with a crazy policeman”.
HPI: Mrs. B is a 45-year-old Caucasian female who presented to the clinic with complaints about having sleepless nights, feeling of euphoria, and being referring as crazy for “fighting for her rights with the policeman”. She separated from her husband 7 years ago and lost her mother 5 years ago. She noted that the symptoms, including nervousness, being overconfident, hyperactivity, alcoholism, engaging in risky sexual episodes and other episodes of sadness, lack of interest in usual hobbies, and low mood started to emerge 3 years ago. She attempted suicide one time and caused financial losses in her workplace after she booked herself boats by the dock for one week without informing anyone and at the expense of the company. She was arrested and caused an altercation in the boat as some party preparations were ongoing, claiming she was the boss. After this episode, she was assessed and diagnosed with bipolar type 1 disorder and she was prescribed Dideral 40 mg, Seralin 50 mg, and Seroguel XR 300 mg. She also reported being very spendthrift at times, something that leaves her broke and miserable. She takes alcohol often; sometimes missing work and her daughter has been overly disappointed with the alcoholism. Sometimes she experiences racing thoughts and feels overly energetic; during these times, she is always very active and her workmates term her as crazy as she comes up with overly ambitious ideas. She reports that she has been using the medications regularly for the last year but stopped 3 months ago. Due to the irregular intake of the medications, she has started feeling unwell and experiencing symptoms such as hyperactivity, being energic, and episodes of sadness, low mood, and loss of interest.
Past Psychiatric History:
Mrs. B was diagnosed with acute depression at the age of 31 years after losing her first employment. She underwent counseling and the symptoms completely improved. She reports the loss of her mother and her separation significantly stressed her. She attempted suicide once. Has never been hospitalized for a mental health issue.
Substance Current Use and History:
She reports excessive alcohol intake, especially when she is stressed. She does not abuse drugs or smoke tobacco. She takes a cup of coffee every evening. She used to smoke pot during her college days.
Family Psychiatric/Substance Use History:
The mother had a history of major depressive disorder. The maternal aunt has schizophrenia, while the paternal uncle was diagnosed with alcoholism. The brother often uses cocaine and opioids without a prescription.
Mrs. B was born and raised in Princeton, New Jersey, USA. She was raised by both parents. The father was a teacher, while the mother was a nurse. She has 2 sisters. She did not have any developmental issues. She is a Buddhist. She has a master’s in MBA from Stanford University. She is an accountant by profession. She is separated from her husband. She describes her marriage as having to be very stressful. She has two daughters who are teenagers. She lives in a rental house in a safe neighborhood with her two daughters. She has medical insurance.
She reports having enjoyed good health. She has never been hospitalized or had major surgery. She had vaginal delivery for both daughters. No history of head trauma, convulsions, or seizures. She takes vitamin C 500 mg daily. She is heterosexual. She is not sexually active.
Weight: 68 kgs; Temp 36.3 0 C; BP 117/75; HR 79; RR 19; No tics or tremors.
- DSM-5 diagnostic criteria: This tool is widely used in the diagnosis of mental health disorders. Mrs. B reported being overconfident, hyperactive, alcoholism, engaging in risky sexual episodes and other episodes of sadness, lack of interest in usual hobbies and low mood. She has a history of a suicide attempt.
- The Mood Disorder Questionnaire (MDQ): MDQ is a succinct, self-report screening tool utilized in identifying clients likely to have bipolar disorder.
Suicide Risk Assessment
Currently no suicidal thoughts or suicide plan. She has a history of a suicide attempt.
Immediate risk: Moderate
Lifetime risk: Moderate
Mental Status Examination:
Mrs. B presents as active and impulsive. Her speech is loud and pressured. Her mood is euphoric and irritable while her affect is labile and heightened. Thought content is grandiose and delusional. She is inattentive and distractible. Her judgment is unrealistically positive as manifested by being unrealistically optimistic and being overly spendthrift. She is well oriented to time, place, person, and event.
Bipolar I Disorder F30.0 (ICD-10): According to the DSM diagnostic criteria, bipolar 1 disorder (manic)is characterized by symptoms such as grandiosity, being overly talkative, reduced need to sleep, high energy levels, reduced attention span, racing thoughts, irritability and engaging in risky behaviors (Lublóy et al., 2020). Mrs. A also has a history of bipolar type 1 disorder. She manifests all the mentioned symptoms and therefore the symptoms fit the diagnosis of bipolar 1 disorder, manic.
Bipolar II Disorder F32.0 (ICD-10): According to the DSM diagnostic criteria, bipolar type 2 disorder is characterized by periods of depressive symptoms and mild mania symptoms. Symptoms of bipolar II disorder include sad mood, sleep disturbances, fatigue, appetite changes, suicidal thoughts, restlessness, feelings of worthlessness and hopelessness, and loss of interest in activities a person once enjoyed, and mild mania episodes (Lublóy et al., 2020. However, Mrs. B mostly manifests manic symptoms and hence does not fit the diagnosis of bipolar I disorder.
Major depressive disorder, F33.1 (ICD-10): DSM-5 diagnostic criteria outline symptoms of major depressive disorder as sad mood, weight changes, appetite changes, fatigue, sleep problems, suicidal thoughts, suicide attempts, psychomotor changes, concentration problems, hopelessness, and impaired thinking ability (Kraus et al., 2019). Even though Mrs. B reported sad mood and suicide attempts previously, she currently manifests symptoms such as racing thoughts, euphoric mood, high energy levels, among other symptoms and thus her current symptoms do not fit the diagnosis of major depressive disorder.
The patient appeared very frustrated but determined to improve. Probably the loss of her mother and her difficult marriage, coupled with separated have played a major role in triggering the current symptoms. The lack of treatment adherence has also contributed to the current symptoms and perhaps adhering to the treatment regimen would ensure complete symptom remission. Therefore, it will be appropriate to educate the patient on the importance of adhering to the treatment regimen and try to find out the reasons for nonadherence. Unwanted side effects are major reasons for medication nonadherence (van der Laan et al., 2019). Mrs. B has a medical insurance and thus she can afford the treatment expenses.
There are various ethical and legal issues when treating patients with mental disorders. For example, patients with bipolar disorder may have psychotic episodes and become violent. Patients with mental disorders may also refuse treatment. Patients with manic episodes may also not respect the boundaries. Therefore, the client’s decisions need to be respected unless she is experiencing a mental crisis and also maintain the required client-therapist relationship.
From this patient, I learned that mental health assessment requires comprehensive health information, physical assessment, and health history to correctly inform the diagnose in order to formulate the correct treatment plan. In the future, I would recommend diagnostics tests such as full blood count and brain scan in order to rule out physical conditions as the cause of the patient’s symptoms.
Case Formulation and Treatment Plan:
The lack of treatment adherence is a major contributing factor to the lack of symptom remission for this patient. Additionally, the loss of the mother and the separation from the husband are also triggers to the bipolar symptoms for this client. Mrs. B has a strong family history of psychiatric disorders since the mother and maternal aunt have mental health disorders while the uncle and the brother have substance use disorders. When formulating the treatment plan, all these factors need to be taken into account. For instance, evidence shows that group psychotherapy may encourage adherence to treatment as clients get to share their experiences and motivate each other (Saldivia et al., 2019).
- Group cognitive-behavioral therapy (group-CBT): Group-CBT is recommended for Mrs. B to help her adopt a more adaptive thinking pattern and also to teach her coping skills to handle life’s negative events such as death or divorce (Neufeld et al., 2020). A group-CBT will also allow Mrs. B to interact with other patients undergoing similar mental health problems and this might improve her treatment adherence.
- As a health promotion activity, the client and other members of the CBT group will be encouraged to engage in their hobbies and ensure they engage in exercise because exercises and physical activities can improve mental health.
- As an education strategy, Mrs. B will be educated regarding the importance of adhering to treatment to ensure complete symptom remission.
- Close follow-up is necessary for Mrs. B because she has a history of suicide attempts and altercations in public.
Kraus, C., Kadriu, B., Lanzenberger, R., Zarate, C. A., Jr, & Kasper, S. (2019). Prognosis and improved outcomes in major depression: a review. Translational psychiatry, 9(1), 127. https://doi.org/10.1038/s41398-019-0460-3
Lublóy, Á., Keresztúri, J. L., Németh, A., & Mihalicza, P. (2020). Exploring factors of diagnostic delay for patients with bipolar disorder: a population-based cohort study. BMC psychiatry, 20(1), 1-17.
Neufeld, C. B., Palma, P. C., Caetano, K., Brust-Renck, P. G., Curtiss, J., & Hofmann, S. G. (2020). A randomized clinical trial of group and individual Cognitive-Behavioral Therapy approaches for Social Anxiety Disorder. International journal of clinical and health psychology: IJCHP, 20(1), 29–37. https://doi.org/10.1016/j.ijchp.2019.11.004
Saldivia, S., Inostroza, C., Bustos, C., Rincón, P., Aslan, J., Bühring, V., … & Cova, F. (2019). Effectiveness of a group-based psychosocial program to prevent depression and anxiety in older people attending primary health care centers: a randomized controlled trial. BMC geriatrics, 19(1), 1-8.
van der Laan, D. M., Elders, P., Boons, C., Nijpels, G., & Hugtenburg, J. G. (2019). Factors Associated with Nonadherence to Cardiovascular Medications: A Cross-sectional Study. The Journal of cardiovascular nursing, 34(4), 344–352. https://doi.org/10.1097/JCN.0000000000000582
The ASSIGNMNET: THE MOOD DISORDER TO USE IS BIPOLAR DISORDER
Select a group patient for whom you conducted psychotherapy for a mood disorder during the last 4 weeks (THE MOOD DISORDER TO USE IS BIPOLAR DISORDER). Create a Comprehensive Psychiatric Evaluation Note on this patient using the template provided in the Learning Resources. USE THE COMPLETED TEMPLATE BELOW AS A GUIDE AND EXAMPLE. PLEASE, DO NOT MISS ANY PART OF THE TEMPLATE , INCLUDE ALL SESSION AS SHOWN IN THE TEMPLATE BELOW. There is also a completed template provided as an exemplar and guide
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 assignments. After reviewing 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
- 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 diagnostic criteria for each differential diagnosis and explain what DSM-5 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 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!), 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 they are 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 who presents for psychotherapeutic evaluation for anxiety. He is currently prescribed sertraline by (?) which he finds ineffective. His PCP referred him for evaluation and treatment.
P.H. is a 16-year-old Hispanic female who presents for psychotherapeutic evaluation for concentration difficulty. She is not currently prescribed psychotropic medications. She is referred by her mental health provider for 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, the duration, the frequency, the severity, and the 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. You will complete a psychiatric ROS to rule out other psychiatric illnesses.
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. (Or, 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.
Psychosocial 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
- 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
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, pseudo hallucinations, 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 yo 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 treatment 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 (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.).
Case Formulation and Treatment Plan.
Includes documentation of diagnostic studies that will be obtained, referrals to other health care providers, therapeutic interventions with psychotherapy, education, disposition of the patient, and any planned follow-up visits. Each diagnosis or condition documented in the assessment should be addressed in the plan. The details of the plan should follow an orderly manner. *see an example below—you will modify to your practice so there may be information excluded/included—what does your preceptor document?
Initiation of (what form/type) of individual, group, or family psychotherapy and frequency.
Documentation of any resources you provide for patient education or coping/relaxation skills, homework for next appointment.
Client has emergency numbers: Emergency Services 911, the Client’s Crisis Line 1-800-_______. Client instructed to go to nearest ER or call 911 if they become actively suicidal and/or homicidal. (only if you or preceptor provided them)
Reviewed hospital records/therapist records for collaborative information; Reviewed PCP report (only if actually available)
Time allowed for questions and answers provided. Provided supportive listening. Client appeared to understand discussion. Client is amenable with this plan and agrees to follow treatment regimen as discussed. (This relates to informed consent; you will need to assess their understanding and agreement.)
Follow up with PCP as needed and/or for:
Write out what psychotherapy testing or screening ordered/conducted, rationale for ordering
Any other community or provider referrals
Return to clinic:
Continued treatment is medically necessary to address chronic symptoms, improve functioning, and prevent the need for a higher level of care OR if one-time evaluation, say so and any other follow up plans.
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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