Case scenario
W S. is a 36-year-old African American male who presents to the clinic for follow-up psychiatric evaluation and medication management with the diagnosis of unspecified depressive disorder and Alcohol/Ecstasy use. Chief complaints: “I’m here for a follow-up.” The patient presents restless, with euthymic mood and affects. He presents with fair insight and judgment. There was no display of psychosis. He reports no significant issues with sleep, appetite, or energy levels. No display of emotional or perpetual disturbance. The thought process is clear and coherent, and the content does not reveal delusion, paranoia, or suicidal ideations. He reports, “my anxiety is a bit worse; I just lost my dad, and I am down a lot lately.” He stated that his current psychotropic has been working for him, but he needs some therapy/counseling due to the recent death in the family. The patient reports having the urge to drink again since this past event in the family. The patient is single but in a relationship. He lives with a friend and renting. Denies any past inpatient or outpatient hospitalization. Denies any past history of family psychiatric illnesses or substance abuse.
Assessment diagnosis: Unspecified depressive disorder, substance abuse disorder, Alcohol abuse, anxiety disorder
Medication: Remeron 30mg PO QHS, Celexa 20 mg PO Q AM, Zoloft 25 mg PO Q daily.
Treatment Plan: The plan is to continue with the current medications and referral for therapy.
The next appointment is to be scheduled in 1 month.
Classroom Productions Links to an external site.. (Producer). (2016). Impulse and conduct disorders [Video]. Walden University.
Professor Hartung. (2020). Multisystemic therapy (MST) for at-risk youth and juveniles informational webinar Links to an external site.[Video]. YouTube. https://www.youtube.com/watch?v=yHbTEWCDlpENRNP/PRAC 6645 Comprehensive Psychiatric
Evaluation Note Template
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
· 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 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 examplNRNP/PRAC 6645 Comprehensive Psychiatric Evaluation Template
Week (enter week #): (Enter assignment title)
Student Name
College of Nursing-PMHNP, Walden University
NRNP 6635: Psychopathology and Diagnostic Reasoning
Faculty Name
Assignment Due Date
Subjective:
CC (chief complaint):
HPI:
(include psychiatric ROS rule out)
Past Psychiatric History:
·
General Statement:
·
Caregivers (if applicable):
·
Hospitalizations:
·
Medication trials:
·
Psychotherapy or
Previous Psychiatric Diagnosis:
Substance Current Use and History:
Family Psychiatric/Substance Use History:
Psychosocial History:
Medical History:
·
Current Medications:
·
Allergies:
·
Reproductive Hx:
Objective:
Diagnostic results:
Assessment:
Mental Status Examination:
Differential Diagnoses:
Reflections:
Case Formulation and Treatment Plan:
References
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