NRNP PRAC 6645: Comprehensive Psychiatric Evaluation Note

NRNP PRAC 6645: Comprehensive Psychiatric Evalution Note

NRNP PRAC 6645: Comprehensive Psychiatric Evaluation Note

FAMILY ASSESSMENT
(https://waldenu.instructure.com/courses/82265/pages/week-2-learning-resources?module_item_id=2461265#:~:text=Masterswork%C2%A0Productions.%C2%A0(2003,%C2%A0%5BVideo/DVD%5D.)

Assessment is as essential to family therapy as it is to individual therapy. Although families often present with one person identified as the “problem,” the assessment process will help you better understand family roles and determine whether the identified problem client is in fact the root of the family’s issues.

 

 

RESOURCES

Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.

WEEKLY RESOURCES

To prepare:

Review this week’s Learning Resources and reflect on the insights they provide on family assessment. Be sure to review the resource on psychotherapy genograms.
Download the Comprehensive Psychiatric Evaluation Note Template and review the requirements of the documentation. There is also an exemplar provided with detailed guidance and examples.
View the Mother and Daughter: A Cultural Tale video in the Learning Resources and consider how you might assess the family in the case study.
THE ASSIGNMENT
Document the following for the family in the video, using the Comprehensive Evaluation Note Template:

Chief complaint
History of present illness
Past psychiatric history
Substance use history
Family psychiatric/substance use history
Psychosocial history/Developmental history
Medical history
Review of systems (ROS)
Physical assessment (if applicable)
Mental status exam
Differential diagnosis—Include a minimum of three differential diagnoses and include how you derived each diagnosis in accordance with DSM-5-TR diagnostic criteria
Case formulation and treatment plan
Include a psychotherapy genogram for the family
Note: For any item you are unable to address from the video, explain how you would gather this information and why it is important for diagnosis and treatment 

 

Week (enter week #): (Enter assignment title)

 

Student Name

College of Nursing-PMHNP, Walden University

NRNP 6645: Psychopathology and Diagnostic Reasoning

Faculty Name

Assignment Due Date

 

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NRNP/PRAC 6645 Comprehensive Psychiatric

Evaluation Note Template

CC (chief complaint):

HPI:

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:

ROS:

  • GENERAL:
  • HEENT:
  • SKIN:
  • CARDIOVASCULAR:
  • RESPIRATORY:
  • GASTROINTESTINAL:
  • GENITOURINARY:
  • NEUROLOGICAL:
  • MUSCULOSKELETAL:
  • HEMATOLOGIC:
  • LYMPHATICS:
  • ENDOCRINOLOGIC:

Physical exam: if applicable

Diagnostic results:

Assessment

Mental Status Examination:

Differential Diagnoses:

Case Formulation and Treatment Plan:

Reflections:

References

 

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 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.
Or
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
• Hobbies
• 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).
Assessment
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 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.).

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?
Example:
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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Family Assessment Mother and Daughter: Comprehensive Psychiatric Evaluation

Patti, an immigrant from Iran to the United States, is the subject of this case. She and her daughter Sharleen, who is 23 years old, went to a psychiatrist for an initial consultation. Their psychotherapist Sandi, who is with them, stays by their side throughout Dr. Gonzalo Bacigalupe’s initial interview. Due to the high mental stress that was caused by factors including spousal violence, child abuse, and family strife, the family required treatment. Patti was forced to have her legs amputated after a disastrous bilateral operation. Despite the fact that she has not been able to sustain herself, it seems like she’s too busy to take care of her kids. The kids have ignored their Iranian cultural upbringing in favor of an American way of life. The purpose of this paper is to provide a comprehensive psychiatric evaluation of the Patti family as depicted in the video of the initial family therapy interview with Patti and her daughter.

Subjective:

CC (chief complaint): She says she is “unhappy”. She is also “desolate because the kids have abandoned me despite my health issues.”

HPI: The lady in question is a mother of five who emigrated from Iran. Her current illness has no prior history with her. Patti’s symptoms began to manifest when her daughter Shireen arrived in the nation and revealed that her father had molested her. The defective systems made her incompetent at that moment. The majority of her concerns are psychological, but the unsuccessful surgeries have also caused her bodily agony. Loneliness and grief have enduring physical manifestations. They are serious, and the absence of the children just heightens their gravity. The signs disappear when her kids are around. She assigns a 7 out of 10 scale to the symptom severity.

Past Psychiatric History:

  • General Statement: The patient is living with disability after failed surgery. She does not have a strong social support network from the family. Her children seem to have abandoned her and this gives her depression.
  • Caregivers (if applicable): She definitely requires having someone take care of her as she is wheelchair-bound.
  • Hospitalizations: Her history of hospitalization is for the failed double operation on her limbs.
  • Medication trials: She has not been put on any neuroleptics before.
  • Psychotherapy or Previous Psychiatric Diagnosis: No previous history.

Substance Current Use and History: Being so religious and from an Islamic state she has no history of substance abuse.

Family Psychiatric/Substance Use History: The family has never used drugs or alcohol. However, the father has a substantial psychological background because he actually has pedophilic condition, which is referred known as “The Paraphilias” along with other sexual problems. He may not be aware of it, but in order to prevent a repeat offense, he has to receive psychiatric care, an examination, and treatment for the disease.

Psychosocial History: The father of Patient P’s five children married her back in Iran. She had to go to the United States for medical care though when one of her children got ill with a strange illness. Then, four of her little children were with her. Due to immigration issues, she left Shireen, now 21 years old, with her father. The kids adapted well to American culture after they arrived. She remained connected to her Iranian culture, though, and encouraged her kids to do the same. But none of this would reach the kids. They abandoned her home and moved out, leaving her alone. She is currently struggling to care for herself and carry out her everyday tasks.

Medical History: None prior to the surgery.

Current Medications: None currently.

Allergies: She does not possess any recognized sensitivities to foods, irritants in the surroundings, or pharmaceuticals.

Reproductive Hx: Patti describes herself as a heterosexual female. She is a mother of five children.

ROS:

  • GENERAL: Patti disputes experiencing weakness, exhaustion, weight loss, or fever and chills.
  • HEENT: She also says she does not have photophobia or double vision. She does not experience headaches, tinnitus, or ear drainage. There have been no reports of sneezing or running noses. Dysphagia and a sore throat are also denied.
  • SKIN: She disputes having rashes or even irritated skin.
  • CARDIOVASCULAR: Denies palpitations, discomfort in the chest, or chest pain. Edema that can be seen is also denied.
  • RESPIRATORY: She disputes any wheezing, discomfort in the chest, coughing, or shortness of breath.
  • GASTROINTESTINAL: She says she does not have diarrhea, vomiting, or nauseous. Additionally, there is no history of bowel irregularities or abdominal discomfort.
  • GENITOURINARY: She disputes frequent urination, painful micturition, passing abnormally large amounts of urine, or passing pee in little volumes. She denies having ever had a sexually transmitted infection.
  • NEUROLOGICAL: She disputes feeling weak on one side, lightheaded, or dizzy. She also disputes experiencing prickling sensations in her extremities. No control over urination or bowel movements is lost.
  • MUSCULOSKELETAL: Arthralgia, back discomfort, and myalgia are not present.
  • HEMATOLOGIC: A clotting problem or any other hematologic condition has not been found in the woman.
  • LYMPHATICS: No lymphadenopathy or splenectomy history is present.
  • ENDOCRINOLOGIC: Negative for excessive urination, excessive thirst, excessive perspiration, cold sensitivity, heat intolerance, or prior use of hormone therapy in terms of endocrinology.

Objective:

Diagnostic results: Imaging investigations were unremarkable. No abnormalities were discovered in any of the other laboratory tests.

Assessment

Mental Status Examination: The individual in question is an Iranian immigrant woman in her forties. In every way, she is focused and attentive. She speaks with clarity and is appropriately attired. She doesn’t seem to have any tics or unusual behaviors. She calls herself “sad” in her statement. Her dysphoric facial expression matches or reflects the state of mind she claimed to be in. She doesn’t experience delusions, hallucinations, or suicidal or violent thoughts. Her intelligence and judgment are unaffected, so she understands that she is sick and needs assistance. The diagnosis is major depressive disorder, or MDD. Its DSM-5-TR diagnostic code is 296.3[F33.1] (APA, 2022; Boland et al., 2021).

Differential Diagnoses:

  1. Major Depressive Disorder or MDD – 296.3[F33.1]

Client P has revealed her genuine thoughts by admitting that she feels helpless and hopeless in her present circumstance. She would like to be near to her children, but they are moving away from her, and she has conveyed this during the session. She feels alone and unworthy as a result of this. She is also saddened by the fact that her own husband violated their daughter’s trust by sexually assaulting her. The Diagnostic and Statistical Manual of Mental Disorders, or DSM-5-TR, fifth edition’s diagnostic criteria for depression appear to be met by all of these specifics (APA, 2022; Boland et al., 2021). MDD is diagnosed as per DSM-5-TR diagnostic criteria when there is:

  1. Reduced interest in enjoyable activities that the patient used to enjoy. M
  2. Mood depression that lasts for the majority of the day on a regular basis for a number of days.
  3. Abnormal sleep patterns like insomnia.
  4. Weakness and marked weight loss.
  5. Self-blame and an unreasonable sense of guilt.
  6. Recurrent thoughts of death and dying but not being able to carry out the same or without a plan (APA, 2022).
  1. Post-traumatic Stress Disorder (PTSD) – 309.81 [F43.10]

            She experienced domestic abuse and saw her own husband assault her youngest child sexually. Traumatic events can result in cognitive alterations, nightmares, and flashbacks (APA, 2022; Boland et al., 2021). But unlike many PTSD sufferers, this individual does not engage in avoidance behavior. She wants to be with her small children more often.

  1. Separation Anxiety Disorder – 309.21[F93.0]

            The individual in question was left alone at home by her adult children, who are now independent adults. Because of the separation, she can be going through psychological symptoms that meet the diagnostic criteria for this disease. One is characterized by unwarranted and excessive worry when they are removed from loved ones to whom they feel a deep attachment (APA, 2022; Boland et al., 2021).

Reflection

I conducted this mental assessment in a thorough manner, and if given the chance again, I would do so. Informed consent was generally assured because the client and her daughter freely sought the assistance of a psychologist with the cooperation of their normal therapist. All standards for history-taking and physical examination were followed as objective and subjective data regarding the patient and her daughter were methodically acquired (Ball et al., 2019). For the client and her daughter, anonymity was a further consideration of ethics in addition to autonomy.

They granted their normal therapist consent to attend, and she was told that they would continue their follow-up therapy with them when they went home. She requested all of her other children to join her for a family therapy session with Dr. Bacigalupe and Sandi because family therapy received more attention during the health education. With the help of this therapy, she would be able to cope with the death of her children. She was also encouraged to start cognitive behavioral treatment, or CBT (Wheeler, 2020), in order to take advantage of cognitive restructuring and improve her thinking and behavior.

Case Formulation and Treatment Plan: She will begin taking medicine and beginning psychotherapy because research shows that they work well together. The measures taken will therefore include the following therapy and selective serotonin reuptake inhibitor or SSRI medication:

  • Sertraline (Zoloft) 100 mg orally every day (Stahl, 2020).
  • Cognitive behavioral therapy (CBT) and family therapy once weekly for 12 weeks (Wheeler, 2020).

 

 

Family Genogram

 

 

References

American Psychiatric Association [APA] (2022). Diagnostic and Statistical Manual of Mental Disorders-Text Revision (DSM-5-TR), 5th ed. Author.

Ball, J., Dains, J.E., Flynn, J.A., Solomon, B.S., & Stewart, R.W. (2019). Seidel’s guide to physical examination: An interprofessional approach, 9th ed. Elsevier.

Boland, R., Verdiun, M., & Ruiz, P. (Eds) (2021). Kaplan and Sadock’s synopsis of psychiatry, 12th ed. Wolters Kluwer.

Mother and Daughter : A Cultural Tale (2003). [Video/ DVD] Masterswork Productions. https://video.alexanderstreet.com/watch/mother-and-daughter-a-cultural-tale

Stahl, S.M. (2020). Stahl’s essential psychopharmacology: Prescriber’s guide, 7th ed. Cambridge University Press.

Wheeler, K. (2020). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice, 3rd ed. Springer Publishing Company, LLC.