Comprehensive Psychiatric Evaluation Note
Psychiatric notes are a way to reflect on your practicum experiences and connect the experiences to the learning you gain from your weekly Learning Resources. Comprehensive psychiatric evaluation notes, such as the ones required in this practicum course, are often used in clinical settings to document patient care.(Comprehensive Psychiatric Evaluation Note for Nursing Students)
For this Assignment, you will document information about a patient that you examined at your practicum site, using the Comprehensive Psychiatric Evaluation Note Template provided. You will then use this note to develop and record a case presentation for this patient. (Comprehensive Psychiatric Evaluation Note for Nursing Students)
Be sure to review the Learning Resources before completing this activity. Click the weekly resources link to access the resources.
- Review this week’s Learning Resources and consider the insights they provide about impulse-control and conduct disorders.
- Select a patient for whom you conducted psychotherapy for an impulse control or conduct disorder during the last 6 weeks. Create a Comprehensive Psychiatric Evaluation Note on this patient using the template provided in the Learning Resources. There is also a completed template provided as an exemplar and guide. All psychiatric evaluation notes must be signed, and each page must be initialed by your Preceptor. When you submit your note, you should include the complete comprehensive evaluation note as a Word document and pdf/images of each page that is initialed and signed by your Preceptor. You must submit your note 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 Grading Policy.(Comprehensive Psychiatric Evaluation Note for Nursing Students)
- Then, based on your evaluation of this patient, develop a video presentation of the case. Plan your presentation using the Assignment rubric and rehearse what you plan to say. Be sure to review the Kaltura Media Uploader resource in the left-hand navigation of the classroom for help creating your self-recorded Kaltura video.(Comprehensive Psychiatric Evaluation Note for Nursing Students)
- Include at least five 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.
Do not sit and read your written evaluation! The video portion of the assignment is a simulation to demonstrate your ability to succinctly and effectively present a complex case to a colleague for a case consultation. The written portion of this assignment is a simulation for you to demonstrate to the faculty your ability to document the complex case as you would in an electronic medical record. The written portion of the assignment will be used as a guide for faculty to review your video to determine if you are omitting pertinent information or including non-essential information during your case staffing consultation video. (Comprehensive Psychiatric Evaluation Note for Nursing Students)
In your presentation:
- Dress professionally 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).(Comprehensive Psychiatric Evaluation Note for Nursing Students)
- Present the full complex case study. Be succinct in your presentation, and do not exceed 8 minutes. Include subjective and objective data; assessment from most recent mental status exam; current psychiatric diagnosis including differentials that were ruled out; current psychotherapeutic plan (include one health promotion activity and one patient education strategy you provided); and patient progress toward treatment goals.
- Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What was the duration and severity of their symptoms? How are their symptoms impacting their functioning(Comprehensive Psychiatric Evaluation Note for Nursing Students)
Comprehensive Psychiatric Evaluation Note for Nursing Students
CC (chief complaint): “I m a trans. I’m on hormone therapy. My former provider does not believe in hormone therapy, that is why I am changing provider.”
HPI: Ms SA is a 25-year-old white female who came to the clinic for psychotherapy and medication management. The client reports becoming anxious and does not want to experience manic episodes again. “I became manic once and no more.” She reported washing her hands, thinking they were dirty until they cracked. She showers constantly. She reports voluntarily taking herself to the hospital when she feels she is going to get manic. The client reports an eating disorder and is afraid to eat around people. The client takes herself off medication whenever she likes. The client reports having too much social energy when around others and talking a lot. She cut her arm and forearm. The client has attempted suicide five times. She last attempted suicide in 2019.(Comprehensive Psychiatric Evaluation Note for Nursing Students)
Past Psychiatric History:
General Statement: The client entered treatment aged five years for ADHD.
Caregivers: No caregivers.(Comprehensive Psychiatric Evaluation Note for Nursing Students)
Hospitalizations: No history of hospitalization reported. Attempted suicide five times. She cut her arm and forearm.
Medication trials: Tried Vyvanse at five years old and stopped. No reason was given for stopping the medication.
Psychotherapy or Previous Psychiatric Diagnosis: The client is diagnosed with ADHD, OCD, and anxiety. The client was diagnosed with bipolar disorder at 16 years. (Comprehensive Psychiatric Evaluation Note for Nursing Students)
Substance Use History: Reports being clean for nine months.
Family Psychiatric/Substance Use History: The mother is bipolar and abused substances. Father has been diagnosed with ADHD and OCD. The father suffered from depression. The father has a history of suicide attempts. The younger sister has been diagnosed with ADHD. The paternal grandmother passed away in 2020 from alcohol abuse-related depression. The client’s paternal grandmother is LGBTQ.
Psychosocial History: Raised by biological parents. Both parents are alive. The mother is abusive. The client lives in New York City. Took care of her siblings at age 11. The client dropped out in the second year of college and is unemployed. No significant legal or violent history.(Comprehensive Psychiatric Evaluation Note for Nursing Students)
Medical History: No significant medical history was reported.
Current Medications: Wellbutrin 600mg PO daily, Abilify 5 mg at HS, and Trileptal 600 mg BD.
Reproductive Hx: Hypersexual.
• GENERAL: Reports 10 lbs weight gain. No fatigue or chills.
• HEENT: No headache, visual problem, hearing loss, nasal congestion, or difficulty swallowing.
• SKIN: No itches or rashes.(Comprehensive Psychiatric Evaluation Note for Nursing Students)
• CARDIOVASCULAR: No chest pain, palpitations, or discomfort. No dyspnea, paroxysmal, or edema.
• RESPIRATORY: No difficulty breathing, cough, or phlegm.
• GASTROINTESTINAL: No abdominal pain or constipation. No nausea, vomiting, or diarrhea.
• GENITOURINARY: Normal bowel and bladder function.
• NEUROLOGICAL: No ataxia, numbness, or tingling in all extremities.
• MUSCULOSKELETAL: No joint pain or swelling. (Comprehensive Psychiatric Evaluation Note for Nursing Students)
• HEMATOLOGIC: No anemia, easy bruising, or bleeding.
• LYMPHATICS: No painful or swollen lymph nodes.
• ENDOCRINOLOGIC: No polyuria or dysuria.
Physical Exams: NA
Vital signs: T- 98.1, R 18, P 92, BP 117/75, H 5.6 W 315 lbs, BMI = 50.8 kg/m2 (Obese Class III)
Diagnostic results: A thyroid-stimulating hormone (TSH) would be crucial in ruling out hyperthyroidism, which affects mood and is often associated with anxiety and depression (Shoib et al., 2021). A result of > 10 mLU/L will indicate hyperthyroidism. A hemoglobin A1C or HbA1c test (A1C) will be crucial in ruling out prediabetes and type 2 diabetes associated with mood changes (Sartorius, 2022). An AIC of below 5.7% will rule out prediabetes or type 2 diabetes. (Comprehensive Psychiatric Evaluation Note for Nursing Students)
Mental Status Examination: Ms SA is well dressed. She is alert and oriented in space, person, and time. She is talkative, cooperative, and conversant. She avoids sustained eye contact. The effect is in full range with anxiety. Her speech is clear, with a broad vocabulary. Her memory is good and recent. The client did not show difficulty with concentration and attention. No psychomotor agitation was observed. Insight is good. Judgment is good. She denies auditory or visual hallucinations. The client shows no signs of delusional thought patterns. Her thought process is coherent, linear, and goal-oriented. Acknowledges current suicide ideation with no intent/plan. The client is at risk of self-harm. (Comprehensive Psychiatric Evaluation Note for Nursing Students)
1. Bipolar I Disorder, moderate with anxious distress 296.42 (F31.12). For an individual to be diagnosed with moderate bipolar I disorder (BD-I) with anxious distress, their symptoms must meet the diagnostic criteria for a manic episode. Manic episodes are characterized by persistently and abnormally elevated mood and increased energy or goal-directed activity that lasts a week and nearly every day, interfering with significant areas of functioning. (American Psychiatric Association [APA], 2019). The mood disturbance is accompanied by symptoms such as grandiosity or unreasonably high self-esteem, talkativeness, flight of ideas, distractibility, psychomotor agitation, and involvement in potentially harmful activities.(Comprehensive Psychiatric Evaluation Note for Nursing Students)
2. Obsessive Compulsive Disorder, 300.3 (F42), with fair insight. The diagnostic criteria for obsessive-compulsive disorder (OCD) presentation of obsessions and/or compulsions, which are time-consuming (APA, 2019). Obsessions are characterized by persistent and recurrent urges/thoughts experienced during disturbances, marked by anxiety and distress, which individuals attempt to suppress, ignore, or neutralize. Compulsions are repetitive actions that individuals are driven to perform, prevent or neutralize an obsession, distress, and anxiety.(Comprehensive Psychiatric Evaluation Note for Nursing Students)
3. Social Anxiety Disorder, 300.23 (F40.10). The diagnostic criteria for social anxiety disorder (SAD) include characteristic anxiety and fear about social situations that present possible scrutiny (APA, 2019). Individuals reports fears of showing anxiety and consequent negative evaluation. Therefore, individuals develop anxiety or fear towards social situations and tend to avoid them. These symptoms should be experienced for a minimum of six months. (Comprehensive Psychiatric Evaluation Note for Nursing Students)
The primary diagnosis is BD-I. The client reported experiencing manic episodes, i.e., elevated and extreme changes in emotions/moods and activity/energy levels. Periods of mania can be subjective or noticeable to others (Wheeler, 2020). The client’s encounters with manic episodes were associated with high social energy, talkativeness, and hypersexual. Moreover, the client reports being anxious about reexperiencing manic episodes and goes to the hospital whenever she feels she will get manic. Contrarily, the client’s experiences suggest OCD. For instance, she reported cutting her arm and forearm. She also reported washing her hands, thinking the hands were dirty until they cracked. She recognizes that these OCD beliefs are not valid. She also showers constantly. Lastly, some of the client’s symptoms suggest SAD. The client has an eating disorder and fears eating in public. There is a possibility of the client fearing public scrutiny considering her weight. However, additional information about her public situation concerns is necessary to ascertain the diagnosis. (Comprehensive Psychiatric Evaluation Note for Nursing Students)
A family history of BD-I supports the primary diagnosis since it is a predisposing factor. Risks of developing BD-I increase with the degree of relationship with family members diagnosed with the disease (APA, 2019). BD-I is common among females and is associated with higher risks of suicide. Underlying traits such as SAD and adverse childhood experiences are determinants of OCD (APA, 2019). SAD is inheritable, and risks increase with the degree of relationship with family members diagnosed with the condition. PMHNP should uphold nonmaleficence and beneficence when dealing with mental health clients, considering the adverse effects of psychotropic medications and the need to minimize the client’s mood disturbances using psychotropic medications. In this regard, there is a need to recommend psychotropic medications, monitor, and provide adjustments to prevent adverse reactions and promote well-being.(Comprehensive Psychiatric Evaluation Note for Nursing Students)
Case Formulation and Treatment Plan.
Pharmacological Intervention: The client is started on a combination of Prozac 20 mg/day in am (the initial dose) and Olanzapine 10 mg/day orally. A combination of Prozac and Olanzapine is recommended for treating and maintaining BD-I symptoms (Luan et al., 2017). The combination is well effective and tolerated. Moreover, Olanzapine is recommended and effective for the treatment of acute OCD and the maintenance of its symptoms (Wilson & Tripp, 2021). Olanzapine is not used off-label for anxiety disorders and would help manage anxiety associated with SAD (Wilson & Tripp, 2021). (Comprehensive Psychiatric Evaluation Note for Nursing Students)
Nonpharmacological Intervention: Start the client on talk therapy. Talk therapy effectively manages mood changes symptoms as clients can discuss their feelings, understand, and develop coping strategies (Nierenberg et al., 2021).
Referrals: The client is referred to an obesity specialist dietician. The dietician is to help the client build confidence, knowledge, and skills to manage her weight (Williams et al., 2019). Besides, the dietitian can also support the client with diet and fitness routines to encourage steady and safe weight loss. (Comprehensive Psychiatric Evaluation Note for Nursing Students)
Education: The client is educated on the importance of a healthy lifestyle and the need to adhere to prescribed medication. Besides, the client is educated on the potential adverse effects of medication and when to contact the clinic. The education session is conducted in the client’s language, and a session for questions is provided.
The client has emergency numbers: Emergency Services 911 and NAMI HelpLine at 1-800-950 when they become suicidal. The local chapters of the National Alliance for mental illness (NAMI) are recommended.
Return to the clinic: After two weeks.(Comprehensive Psychiatric Evaluation Note for Nursing Students)
American Psychiatric Association. (2019). Diagnostic and statistical manual of mental disorders (7th ed.). American Psychiatric Publishing, Inc. (Comprehensive Psychiatric Evaluation Note for Nursing Students)
Nierenberg, A. A., Harris, M. G., Kazdin, A. E., Puac‐Polanco, V., Sampson, N., Vigo, D. V., … & WHO World Mental Health Survey Collaborators. (2021). Perceived helpfulness of bipolar disorder treatment: findings from the World Health Organization World Mental Health Surveys. Bipolar Disorders, 23(6), 565-583. https://doi.org/10.1111/bdi.13066
Luan, S., Wan, H., Wang, S., Li, H., & Zhang, B. (2017). Efficacy and safety of olanzapine/fluoxetine combination in treating treatment-resistant depression: a meta-analysis of randomized controlled trials. Neuropsychiatric Disease and Treatment, 13, 609. https://doi.org/10.2147%2FNDT.S127453 (Comprehensive Psychiatric Evaluation Note for Nursing Students)
Sartorius, N. (2022). Depression and diabetes. Dialogues in Clinical Neuroscience. https://doi.org/10.31887%2FDCNS.2018.20.1%2Fnsartorius
Shoib, S., Ahmad, J., Wani, M. A., Ullah, I., Tarfarosh, S. F. A., Masoodi, S. R., & Ramalho, R. (2021). Depression and anxiety among hyperthyroid female patients and impact of treatment. Middle East Current Psychiatry, 28(1), 1-6. https://doi.org/10.1186/s43045-021-00107-7
Williams, L. T., Barnes, K., Ball, L., Ross, L. J., Sladdin, I., & Mitchell, L. J. (2019, February). How effective are dietitians in weight management? A systematic review and meta-analysis of randomized controlled trials. In Healthcare (Vol. 7, No. 1, p. 20). MDPI. https://doi.org/10.3390%2Fhealthcare7010020 (Comprehensive Psychiatric Evaluation Note for Nursing Students)
Wilson, M., & Tripp, J. (2021). Clomipramine. In StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK541006/#__NBK541006_ai
Wheeler, K. (2020). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice. Springer Publishing Company.(Comprehensive Psychiatric Evaluation Note for Nursing Students)