Comprehensive Psychiatric Evaluation Essay
Chief complaint: “ the teacher is worried about my concentration in class”
History of presenting complaint: Serah is a 10years old white female accompanied by her mother due to her inability to concentrate in class. She states that she has a short concentration span and the teacher complaints about it a lot. She fidgets a lot, gets out of her chair, loses memory, does not finish her school activities, is easily distracted, makes mistakes in her school work, cannot follow through with instructions, cannot take turns when playing games, loses her items, daydreams, and loses her temper easily. Comprehensive Psychiatric Evaluation Essay
Medication trials: none
Current medications: cetirizine 5mg PO prn for allergic rhinitis.
Previous psychiatric diagnosis: none
Pertinent substance use and family psychiatric history: her mother has a generalized anxiety disorder and her father has substance-induced psychosis. Her father cracks cocaine, smokes a cigarette, and takes alcohol daily. her mother takes four beers daily and smokes marijuana occasionally.
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Past medical history: she has seasonal allergic rhinitis. She denies hospitalization and blood transfusion.
Allergies: she is allergic to pollen and animal fur.
Social history: she is in grade 6, and lives with her father. Her mother separated from her father after a series of domestic violence. She performs well in class and plays in external activities and sports. She denies the use of alcohol and cigarettes.
Family history: she is the only child in her family. Her mother has generalized anxiety disorder and hypertension. Her father has asthma, diabetes mellitus, and alcohol-induced psychosis.
Review of systems
General: fatigue, weight loss, night sweats, malaise, chills, and rigors.
HEENT: The patient denies headache, eye ache, blurring of vision, runny nose, throat pain, neck pain, and loss of hearing.
Respiratory system: the patient denies coughing, chest pain, wheezing, shortness of breath, and sputum production. Comprehensive Psychiatric Evaluation Essay
Cardiovascular system: the patient denies palpitations, chest pain, tachycardia, lower limb swelling, dyspnea, syncope, orthopnea, and paroxysmal nocturnal dyspnea.
Gastrointestinal system: she denies abdominal pain, nausea, vomiting, diarrhea, heartburn, reflux, and GERD.
Genitourinary system: the patient denies dysuria, hematuria, polyuria, oliguria, incontinence, vaginal discharge, and vulva itchiness.
Endocrine system: the patient denies night sweats, weight loss, changes in cholesterol, changes in blood glucose levels, and mood swings.
Musculoskeletal system: the patient denies joint pain, a history of fracture, muscle spasms, stiffness, and swelling of the joints.
Hematological system: she denies headache, dizziness, fatigue, bleeding tendencies, easy bruising, pale skin, cold extremities, and a history of anemia.
Lymphatic system: the patient denies swelling of the lower limb, recurrent infections, pain at the lymph nodes, and skin discoloration.
Integumentary system: she denies breaking of the hair and nails, skin acne, itchiness, and scaling.
Neurological system: the patient denies numbness, tingling sensation, facial droop, tremors, coma, and consciousness:
General: the patient is calm and alert. She has no pallor, cyanosis, lymphadenopathy, finger clubbing, and jaundice.
Respiratory system: the patient has a symmetrical chest expansion without flaring of nasal alae, lower chest wall indrawing, and intercostal resection. There are no mass, therapeutic marks, and scars. There is a symmetrical vocal fremitus and resonant percussion note. There are vesicular breath sounds without crepitations, rhonchi, and stridor.
Cardiovascular system: the heart is palpable at the 5th intercoastal space mid-clavicular line. There are no parasternal heaves and thrills. The heart sounds s1 and s2 are present murmurs and gallop. The peripheral pulse is present at a regular rate, and rhythm, and without bruits. There is no anasarca and peripheral edema.
Abdominal examination: the abdomen is round without flank fullness. The bowel sounds are present in the four quadrants. There is no organ enlargement and there are no areas of tenderness. There is a tympanic percussion note without shifting dullness and fluid thrills. Comprehensive Psychiatric Evaluation Essay
Neurological test: the cranial nerves and all reflexes are intact. The muscle bulk is normal bilaterally in the upper and lower limbs. There are active movements of the limbs with no changes in tone. The muscle power is 5 out of 5 in all the limbs.
Diagnostic tests: thyroid function tests rule out hyperthyroidism and hypothyroidism. A liver function test rules out liver diseases such as acute liver failure. Renal function tests rule out diseases like acute kidney injury and acute glomerulonephritis. complete blood count with differentials to rule out anemia and sepsis. These diseases present with symptoms of confusion, loss of memory, and hyperactivity.
Mental state examination
The patient is alert and oriented to time, place, and person. She is appropriately dressed for the event and weather. She is easy to initiate a conversation with because she answers questions promptly. She avoids eye contact and fidgets a lot during the interview. Her speech is clear and coherent in normal tone and volume, though she seems to forget questions easily. She is in a happy mood and has a broad affect. Her thought process is congruent with no evidence of flight of ideas. Her insight and judgment are slightly off. She has no suicidal thoughts, hallucinations, and delirium.
Attention deficit hyperactivity disorder ADHD is a mental health disorder characterized by inattention and distractibility. The onset of ADHD is about twelve years or less. The disturbance in this disease affects activities at home, school, or both leading to poor academic or performance outcomes. ADHD can be predominantly hyperactive, predominantly inattentive, or both. Children with inattentive ADHD present with a lack of attention to complete work, making careless mistakes in school work, difficulties in sustaining attention in play work, difficulties in organizing tasks, losing items, disliking school work, and forgetting their daily activities (Faraone, et al, 2021). The impulsive type fidgets a lot, climbs excessively, has difficulties in engaging in leisure activities, talks excessively, has difficulties in waiting for turns, and interrupts activities. The mother states that her daughter has reduced concentration span, fidgets a lot, has loss of memory, has difficulties in waiting for turns, and loses items easily. Therefore, she has both inattention and distractibility attention deficit hyperactive disorder.
Depression is a mental disorder characterized by loss of emotional expression, restlessness, and psychomotor agitation. It is common in both children and adults due to genetic predisposition, traumatic events, impaired social support, negative life events, loneliness, bereavement, and poor parenting. Depression presents with loss of concentration, impaired sleep, significant weight changes, loss of memory, fatigue, feelings of worthlessness, agitation, and recurrent suicidal ideation. A patient with depression has slow pressured speech with monotony content (Alexopoulos, et al, 2019). They display a spontaneous movement with a loss of emotional expression. The patient presents with agitation, loss of memory, and impaired concentration. However, this is not the primary diagnosis because the patient does not meet the criteria for depression. According to the American psychiatric association, a patient must present with sadness, suicidal ideation, increased sleep, significant weight gain, and hopelessness to meet the criteria.
Anxiety disorder is a common psychiatric disorder from childhood to adulthood. Anxiety is excessive fear or worry of an event that leads to a change of behavior and perception. Separation anxiety disorder is the most common in children due to abandonment by their parents or caregiver. Other types of anxiety disorders are agoraphobia, social phobia, and panic attacks. Causes of anxiety disorders are genetic predisposition, stress, trauma, and poor parenting. The presenting symptoms are sweating, trembling, irritability, sleep disturbance, loss of concentration, restlessness, and muscle tension. Upon examination, they are cooperative at the level of speech, mood, affect, and activity (DeMartini, et al, 2019. However, they tend to be easily distracted and are restless. The patient presents with similar symptoms of restlessness, agitation, loss of concentration, and impaired memory. However, she does not meet the DSM 5 criteria for anxiety disorder because she has no specific fear or worry. Comprehensive Psychiatric Evaluation Essay
It was an interesting experience to assess a patient with attention deficit hyperactive disorder. The patient was calm throughout the interview, hence, changing my perspective of children with ADHD. The child seems to have a combination of both hyperactive and inattention behavior because he could fidget a lot during the interview and have episodes of loss of concentration. I agree with the diagnosis because the patient presents with similar symptoms hence meeting the American psychiatric association diagnostic criteria. In my next interview, I will use open-ended questions and I will carry out a variety of assessment tools for psychiatric diseases to rule out other causes of the symptoms. When treating this patient, I will incorporate ethical principles such as beneficence, respect for autonomy, and non-maleficence. Beneficence is acting in the patient’s best interest by prescribing the best drug and scheduling follow-up clinics to ensure they recover (Bifarin, O., & Stonehouse, D. 2022). Non-maleficence is protecting the patient from harm by prescribing medication with no side effects. Autonomy is respecting the patient’s medical decisions. The patient has a right to accept and decline treatment.
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:
Differential Diagnoses: Comprehensive Psychiatric Evaluation Essay
Alexopoulos, G.S. Mechanisms and treatment of late-life depression. Transl Psychiatry 9, 188 (2019). https://doi.org/10.1038/s41398-019-0514-6
Bifarin, O., & Stonehouse, D. (2022). Beneficence and non-maleficence: collaborative practice and harm mitigation. British Journal of Healthcare Assistants, 16(2), 70-74. https://doi.org/10.12968/bjha.2022.16.2.70
DeMartini, J., Patel, G., & Fancher, T. L. (2019). Generalized anxiety disorder. Annals of internal medicine, 170(7), ITC49-ITC64. https://doi.org/10.7326/AITC201904020
Faraone, S. V., Banaschewski, T., Coghill, D., Zheng, Y., Biederman, J., Bellgrove, M. A., … & Wang, Y. (2021). The world federation of ADHD international consensus statement: 208 evidence-based conclusions about the disorder. Neuroscience & Biobehavioral Reviews, 128, 789-818. https://doi.org/10.1016/j.neubiorev.2021.01.022
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
- 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-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:
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. 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? Comprehensive Psychiatric Evaluation Essay
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.
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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? Comprehensive Psychiatric Evaluation Essay
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 Comprehensive Psychiatric Evaluation Essay
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, 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-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?
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.). Comprehensive Psychiatric Evaluation Essay
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.
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? 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 Essay