Comprehensive Psychiatric Evaluation and Patient Case Presentation

Select a patient that you examined during who presented with a psychotic (it has to be psychosis/mania/schizophrenia) disorder. Conduct a Comprehensive Psychiatric Evaluation on this patient using the template provided. Please every aspect must be filled; please physical, diagnostics, medication trials, and so on has to be completed.

Comprehensive psychiatric evaluation is necessary to diagnose the behavioral, emotional, or developmental disorder. The psychiatric evaluation is normally based on the cognitive, social, emotional, and physical behaviors. Comprehensive psychiatric evaluation involves a description of the behavior and symptoms; the impact of the behaviors on work, academic, and interpersonal relationships; interview; psychiatric health history; family mental health history; complete health history, and diagnostic/lab tests. The purpose of this paper is to conduct a comprehensive psychiatric evaluation for a patient who presented for assessment with complaints about memory loss and experiencing vivid nightmares. Comprehensive Psychiatric Evaluation and Patient Case Presentation.

CC (chief complaint): “I have been so forgetful for the last one year, I do not sleep well and end up experiencing nightmares…these symptoms, especially forgetfulness has messed with my daily life. I cannot focus and sometimes I even forget when I cooking or forget directions when I am going home… this is too much….”

HPI: XX is a 62-year-old Caucasian male who presents for his first psychiatric evaluation accompanied after being referred by his primary care provider (PCP). XX was accompanied by his wife, who lives with him. The son reported that the PCP had performed a comprehensive diagnostic workup that ruled out any organic causes for his cognitive changes. XX’s wife reported that she was concerned that her husband may have Alzheimer’s disease.

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XX reports that he has always been somehow forgetful, especially in the last 2 years but for the last 1 year the forgetfulness has gotten worse. He states that he does not even know how bad his memory has deteriorated. Mr. XX has gotten lost at least three times when driving to the market…. he tries to protest this indicating that the ongoing road constructions are confusing, but his wife points out the confusion while driving due to the memory loss. The wife reports the forgetfulness has caused Mr. XX to make errors in paying monthly bills, where he totally forgets about the bills and hence the wife has taken over the responsibility, something that has never happened. Comprehensive Psychiatric Evaluation and Patient Case Presentation.  Mr. XX also has been unable to effectively manage his medications, where in the last 2 months he overdosed on Norvasc pill, which led to hypotension and a fall. Other times he forgets to take the Norvasc medication. As a result, the wife has set up XX’s pills in pillboxes, but he still misses doses. The wife reports that Mr. XX’s cognition varies and becomes worse in the evening. The wife states that XX appears less alert and not focused in the evening, but is more focused during morning hours.

Mr. XX reports poor sleep for a while and reports that he has been having vivid dreams and vivid nightmares. The wife states that sometimes the husband wakens her while yelling and shouting during nightmares, and Mr. xx kicks and swings his legs while asleep.

Mr. XX reports that his appetite is okay and he normally has fluctuating energy levels where sometimes he is able to focus and concentrate very well, while other times he cannot focus, which he reports is very frustrating. He reported enjoying a glass of wine during supper but admits he no longer finds that interesting because when he drinks, he begins to experience slow muscle contractions. The wife is also concerned about his abnormal movements and problems with coordination that began 4 months ago.

Past Psychiatric History

Mr. xx was first diagnosed with the major depressive disorder at the age of 30 years. He was treated using sertraline for a period of six months.  He also attended psychotherapy treatment (group-cognitive behavioral therapy) for 12 sessions. At the end of the CBT therapy and sertraline medication, he achieved complete symptom remission.

Substance Use History

He is drinks alcohol regularly and he started taking alcohol at the age of 20 years during his college education. He used to smoke pot during his college days but stopped smoking pot at the age of 30 years. He has never taken any illegal drugs.

Family Psychiatric/Substance Use History

His father died at the age of 80 years and her past psychiatric history included major depressive disorder and schizophrenia. The mother succumbed to suicide at the age of 60 years. She had a history of bipolar type 1 disorder. The brother has a history of alcohol use disorder.

Social History

Mr. xx was born in the USA, California. He was raised by his mother and father. However, the parents were both working and thus the nanny was his major caregiver. He is the firstborn in a family of two children (him and the brother). Mr. xx currently owns a home and lives with his wife. He has two children who live in a nearby estate and they occasionally visit him.

His highest level of education is a college degree. His hobbies include watching television, playing chess, and cycling. However, he reports that lately, he is not able to enjoy his favorite hobbies, especially playing chess and cycling.

Currently, he is retired and used to work as a civil engineer with a big engineering firm. He receives a pension and also has other sources of income such as real estate that provide him and his wife with adequate income. His children are also very supportive both emotionally and financially as per the wife’s report.

He does not have any past history of trauma, violence, or any relevant legal history. Comprehensive Psychiatric Evaluation and Patient Case Presentation. 

Medical History

Mr. xx was diagnosed with high blood pressure at the age of 55 years and he has been managing the condition using mediation and diet change. At 48-years-old, he underwent an appendectomy. He reports that at age of 24-years he suffered a severe head injury after a cycling accident and was hospitalized for 20 days. He denied any history of seizures or any CNS problem such as lightheadedness or tingling.

Current Medications

Mr. xx has been taking Norvasc 5 mg daily to treat hypertension. He has been taking Norvasc for the last 7 years. He takes vitamin and calcium supplements for the last 4 years. He occasionally takes Panadol whenever he has a headache.

Allergies

He is allergic to penicillin and develops a rash after taking penicillin. He denied any other seasonal allergy or food allergy.

Reproductive Hx

He is in a monogamous relationship with the wife. He reports that he is sexually active. The wife reported that he occasionally takes avanafil (Stendra) to improve his sex life.

Review of Systems (RoS)

General: He appears well-groomed for his age. No recent weight loss. He appears calm, but fatigued and lethargic.

HEENT: Denied any headache, eye problem, ear problem, sore throat, swallowing difficulties, runny nose, sneezing, or neck pain.

Skin: Reports dry skin, scalp on the head. No skin itching or rash

Cardiovascular: No palpitations; no chest tightness; no chest pain; no edema

Respiratory: No cough; no breath shortness; no running nose

Gastrointestinal: No abdominal pain, vomiting, nausea, or diarrhea.

Genitourinary: No pain or burning sensation during urination. No odor or urine discoloration

Neurological: Reports forgetfulness and confusion, No headache, tingling, dizziness, numbness, or lightheadedness. No change in bowel movement.

Musculoskeletal: Reports slowed movement and joint stiffness. Denies any joint pain or muscle pain.

Hematologic: No bleeding or anemia

Lymphatics: Normal lymph nodes.

Endocrinologic: Denies excessive sweating; no heat or cold intolerance. No polyuria.

Physical Examination

Head: Normocephalic; no dandruff; no noted abnormality

Neurological: Alert and oriented to place, person, and partially oriented to time. His speech is coherent, clear, spontaneous, and goal-directed. Judgment intact but impaired insight. Attention and concentration are also impaired. Major deficits in the recall, calculation, and orientation. His sensory is alright. Abnormality was noted on motor function and balance, especially in the lower extremities.

Musculoskeletal: No atrophy or deformity in bilateral upper extremities. Full range of motion on all bilateral upper extremities. No evidence of swollen joints. Reduced range of motion in the bilateral lower extremities. No evidence of swollen joints in the bilateral lower extremities. Bilateral upper and lower extremities strength equal and 5/5 in all joints. 

Diagnostic Tests

Brain scans: Brain scans such as Magnetic resonance imaging scans (MRI) and (FDG-PET) scans can be used to identify any visible abnormality for the brain that may be causing the symptoms for this patient.

SPECT or PET imaging (DAT uptake): This diagnostic test allows the integrity of the nigrostriatal pathway to be examined in order to identify any neuronal degeneration (Palermo & Ceravolo, 2019).

Iodine-MIBG myocardial scintigraphy to determine synucleinopathy: This test is useful in confirming the diagnosis of major neurocognitive disorder with Lewy bodies (Sakamoto et al., 2016).

Assessment

Vital signs:

• Temperature 36. 8 C
• Heart rate: 78
• Respiration rate: 17
• Blood pressure 128/82 mm Hg
• BMI 24
• Pain N/A

Mental Status Examination

Mr. XX appears alert and oriented to place, person, and partially oriented to time as he is aware that it is in the morning, but does not know the hour. His speech is coherent, clear, spontaneous, and goal-directed. Comprehensive Psychiatric Evaluation and Patient Case Presentation. Mr. XX’s self-reported mood is that “he feels good”. His affect appears constricted. During the clinical interview, Mr. XX’s eye contact is fleeting. Mr. xx denied auditory or visual hallucinations. Judgment is intact. No paranoid thought process or overt delusional. Impaired insight as Mr. xx has difficulties understanding the reasons the wife brought him for psychiatric evaluation. Attention and concentration were also impaired and as a result, a mini-mental status exam (MMSE) on Mr. xx was performed. Mr. xx scored 17 on the MMSE, with major deficits in the recall, calculation, and orientation. Mr. xx was not able to remember any of the 4 items presented after five minutes and he could also not perform serial 7’s or spell the word “read” in reverse, in spite that he has a college degree. He also required prompting using the 3-step command. The MMSE score of 17 indicates severe cognitive impairment for Mr. XX.

Differential Diagnoses

• Major neurocognitive disorder with Lewy bodies: This neurocognitive disorder is characterized by symptoms like attention and concentration impairment; parkinsonian motor signs; rapid eye movement (REM) sleep behavior disorder, and visual hallucinations (Gomperts, 2016). Mr. xx has symptoms such as slowing movement and rest tremor manifesting parkinsonian motor signs; (REM) sleep behavior disorder; and impaired attention and concentration. The symptoms Mr. xx manifests match the symptoms of the neurocognitive disorder with Lewy bodies confirming this diagnosis.
• Major neurocognitive disorder due to Alzheimer’s disease: This disorder is characterized by a progressive decline in cognitive function, a decline in memory, and an indication of causative disease genetic mutation from genetic testing or family history (Dindelegan et al., 2020). However, this disorder is not characterized by REM sleep behavior disorder, and this rules out major neurocognitive disorder due to Alzheimer’s disease for Mr. xx.
• Major frontotemporal neurocognitive disorder (FTNCD): This disorder is characterized by movement disorders; improper social behavior; lack of interpersonal skills and empathy; lack of inhibition; lack of judgment apathy’ repetitive compulsive behavior; changes in personal hygiene; inappropriate feeding habits; and speech and language problems (Young et al., 2018). Mr. xx does not manifest the majority of these symptoms and, this rules out FTNCD for this patient.

Findings

According to the DSM-5 diagnostic criteria and the brain scan (MRI) identifying pathologically and intracytoplasmic Lewy bodies within the subcortical nuclei, neocortex, and limbic cortex, confirming the diagnosis of major neurocognitive disorder with Lewy bodies.

Diagnosis

Major neurocognitive disorder with Lewy bodies

Reflection

A comprehensive psychiatric assessment was performed for this patient. The assessment involved collected detailed patient information by interviewing the patient and the wife (caregiver) to collect the correct subjective information.  Comprehensive Psychiatric Evaluation and Patient Case Presentation.The objective data was collected through physical examination and mental status exam. This enabled us to arrive at the appropriate differential diagnoses. Given another opportunity, I would widely use the latest and best available evidence to research about the comprehensive assessment and the possible differential diagnoses for this patient.

Ethical considerations relevant when evaluating this patient include his decision-making ability and informed consent. The client and the wife need to be informed and educated about the comprehensive psychiatric assessment to ensure informed consent is obtained from them (Hedge & Ellajosyula, 2016). Additionally, since the patient seems to be impaired cognitively, it would be important to assess his decision-making ability.

Conclusion

According to the findings and the collected subjective and objective data, the diagnosis for the client is major neurocognitive disorder with Lewy bodies. The recommended pharmacological treatment choice for this client include memantine due to the medication’s efficacy in improving behavioral symptoms in Major Neurocognitive Disorder with Lewy Bodies, reduces brain deterioration, treats REM sleep behavior disorder, and also improves cognition and motor skills (Persoons, 2016). 

References

Dindelegan, C. M., Faur, D., Purza, L., Bumbu, A., & Sabau, M. (2020). Distress in neurocognitive disorders due to Alzheimer’s disease and stroke. Experimental and therapeutic medicine, 20(3), 2501–2509. https://doi.org/10.3892/etm.2020.8806

Gomperts S. (2016). Lewy Body Dementias: Dementia with Lewy Bodies and Parkinson’s Disease Dementia. Continuum (Minneap Minn), 22(2), 435–463.

Hedge S & Ellajosyula R. (2016). Capacity issues and decision-making in dementia. Ann Indian Acad Neurol, 19(1), S34–S39.

Palermo, G., & Ceravolo, R. (2019). Molecular Imaging of the Dopamine Transporter. Cells, 8(8), 872. https://doi.org/10.3390/cells8080872

Persoons V. (2016). Early use of memantine in the treatment of Lewy body dementia]. Tijdschr Psychiatr, 58(11), 814-817.

Sakamoto, F., Shiraishi, S., Tsuda, N., Ogasawara, K., Yoshida, M., Yuki, H., Hashimoto, M., Tomiguchi, S., Ikeda, M., & Yamashita, Y. (2016). ¹²³I-MIBG myocardial scintigraphy for the evaluation of Lewy body disease: is delayed images essential? Is visual assessment useful? The British journal of radiology, 89(1064), 20160144. https://doi.org/10.1259/bjr.20160144

Young, J. J., Lavakumar, M., Tampi, D., Balachandran, S., & Tampi, R. R. (2018). Frontotemporal dementia: latest evidence and clinical implications. Therapeutic advances in psychopharmacology, 8(1), 33–48. https://doi.org/10.1177/2045125317739818

Comprehensive Psychiatric Evaluation and Patient Case Presentation

CC (chief complaint): “I have been so forgetful for the last one year, I do not sleep well and end up experiencing nightmares…these symptoms, especially forgetfulness has messed with my daily life. Comprehensive Psychiatric Evaluation and Patient Case Presentation.  I cannot focus and sometimes I even forget when I cooking or forget directions when I am going home… this is too much….”

HPI: XX is a 62-year-old Caucasian male who presents for his first psychiatric evaluation accompanied after being referred by his primary care provider (PCP). XX was accompanied by his wife, who lives with him. The son reported that the PCP had performed a comprehensive diagnostic workup that ruled out any organic causes for his cognitive changes. XX’s wife reported that she was concerned that her husband may have Alzheimer’s disease.

XX reports that he has always been somehow forgetful, especially in the last 2 years but for the last 1 year the forgetfulness has gotten worse. He states that he does not even know how bad his memory has deteriorated. Mr. XX has gotten lost at least three times when driving to the market…. he tries to protest this indicating that the ongoing road constructions are confusing, but his wife points out the confusion while driving due to the memory loss. The wife reports the forgetfulness has caused Mr. XX to make errors in paying monthly bills, where he totally forgets about the bills and hence the wife has taken over the responsibility, something that has never happened. Mr. XX also has been unable to effectively manage his medications, where in the last 2 months he overdosed on Norvasc pill, which led to hypotension and a fall. Other times he forgets to take the Norvasc medication. As a result, the wife has set up XX’s pills in pillboxes, but he still misses doses. The wife reports that Mr. XX’s cognition varies and becomes worse in the evening. The wife states that XX appears less alert and not focused in the evening, but is more focused during morning hours.

Mr. XX reports poor sleep for a while and reports that he has been having vivid dreams and vivid nightmares. The wife states that sometimes the husband wakens her while yelling and shouting during nightmares, and Mr. xx kicks and swings his legs while asleep.

Mr. XX reports that his appetite is okay and he normally has fluctuating energy levels where sometimes he is able to focus and concentrate very well, while other times he cannot focus, which he reports is very frustrating. He reported enjoying a glass of wine during supper but admits he no longer finds that interesting because when he drinks, he begins to experience slow muscle contractions. The wife is also concerned about his abnormal movements and problems with coordination that began 4 months ago. Comprehensive Psychiatric Evaluation and Patient Case Presentation.

Past Psychiatric History

Mr. xx was first diagnosed with the major depressive disorder at the age of 30 years. He was treated using sertraline for a period of six months.  He also attended psychotherapy treatment (group-cognitive behavioral therapy) for 12 sessions. At the end of the CBT therapy and sertraline medication, he achieved complete symptom remission.

Substance Use History

He is drinks alcohol regularly and he started taking alcohol at the age of 20 years during his college education. He used to smoke pot during his college days but stopped smoking pot at the age of 30 years. He has never taken any illegal drugs.

Family Psychiatric/Substance Use History

His father died at the age of 80 years and her past psychiatric history included major depressive disorder and schizophrenia. The mother succumbed to suicide at the age of 60 years. She had a history of bipolar type 1 disorder. The brother has a history of alcohol use disorder.

Social History

Mr. xx was born in the USA, California. He was raised by his mother and father. However, the parents were both working and thus the nanny was his major caregiver. He is the firstborn in a family of two children (him and the brother). Mr. xx currently owns a home and lives with his wife. He has two children who live in a nearby estate and they occasionally visit him.

His highest level of education is a college degree. His hobbies include watching television, playing chess, and cycling. However, he reports that lately, he is not able to enjoy his favorite hobbies, especially playing chess and cycling.

Currently, he is retired and used to work as a civil engineer with a big engineering firm. He receives a pension and also has other sources of income such as real estate that provide him and his wife with adequate income. His children are also very supportive both emotionally and financially as per the wife’s report.

He does not have any past history of trauma, violence, or any relevant legal history.

Medical History

Mr. xx was diagnosed with high blood pressure at the age of 55 years and he has been managing the condition using mediation and diet change. At 48-years-old, he underwent an appendectomy. He reports that at age of 24-years he suffered a severe head injury after a cycling accident and was hospitalized for 20 days. He denied any history of seizures or any CNS problem such as lightheadedness or tingling. Comprehensive Psychiatric Evaluation and Patient Case Presentation. 

Current Medications

Mr. xx has been taking Norvasc 5 mg daily to treat hypertension. He has been taking Norvasc for the last 7 years. He takes vitamin and calcium supplements for the last 4 years. He occasionally takes Panadol whenever he has a headache.

Allergies

He is allergic to penicillin and develops a rash after taking penicillin. He denied any other seasonal allergy or food allergy.

Reproductive Hx

He is in a monogamous relationship with the wife. He reports that he is sexually active. The wife reported that he occasionally takes avanafil (Stendra) to improve his sex life.

Review of Systems (RoS)

General: He appears well-groomed for his age. No recent weight loss. He appears calm, but fatigued and lethargic.

HEENT: Denied any headache, eye problem, ear problem, sore throat, swallowing difficulties, runny nose, sneezing, or neck pain.

Skin: Reports dry skin, scalp on the head. No skin itching or rash

Cardiovascular: No palpitations; no chest tightness; no chest pain; no edema

Respiratory: No cough; no breath shortness; no running nose

Gastrointestinal: No abdominal pain, vomiting, nausea, or diarrhea.

Genitourinary: No pain or burning sensation during urination. No odor or urine discoloration

Neurological: Reports forgetfulness and confusion, No headache, tingling, dizziness, numbness, or lightheadedness. No change in bowel movement.

Musculoskeletal: Reports slowed movement and joint stiffness. Denies any joint pain or muscle pain.

Hematologic: No bleeding or anemia

Lymphatics: Normal lymph nodes.

Endocrinologic: Denies excessive sweating; no heat or cold intolerance. No polyuria.

Physical Examination

Head: Normocephalic; no dandruff; no noted abnormality

Neurological: Alert and oriented to place, person, and partially oriented to time. His speech is coherent, clear, spontaneous, and goal-directed. Judgment intact but impaired insight. Attention and concentration are also impaired. Major deficits in the recall, calculation, and orientation. His sensory is alright. Abnormality was noted on motor function and balance, especially in the lower extremities.

Musculoskeletal: No atrophy or deformity in bilateral upper extremities. Full range of motion on all bilateral upper extremities. No evidence of swollen joints. Reduced range of motion in the bilateral lower extremities. No evidence of swollen joints in the bilateral lower extremities. Bilateral upper and lower extremities strength equal and 5/5 in all joints.

Diagnostic Tests

Brain scans: Brain scans such as Magnetic resonance imaging scans (MRI) and (FDG-PET) scans can be used to identify any visible abnormality for the brain that may be causing the symptoms for this patient.

SPECT or PET imaging (DAT uptake): This diagnostic test allows the integrity of the nigrostriatal pathway to be examined in order to identify any neuronal degeneration (Palermo & Ceravolo, 2019).

Iodine-MIBG myocardial scintigraphy to determine synucleinopathy: This test is useful in confirming the diagnosis of major neurocognitive disorder with Lewy bodies (Sakamoto et al., 2016).

Assessment

Mental Status Examination

Mr. XX appears alert and oriented to place, person, and partially oriented to time as he is aware that it is in the morning, but does not know the hour. His speech is coherent, clear, spontaneous, and goal-directed. Mr. XX’s self-reported mood is that “he feels good”. His affect appears constricted. During the clinical interview, Mr. XX’s eye contact is fleeting. Mr. xx denied auditory or visual hallucinations. Judgment is intact. No paranoid thought process or overt delusional. Impaired insight as Mr. xx has difficulties understanding the reasons the wife brought him for psychiatric evaluation.Comprehensive Psychiatric Evaluation and Patient Case Presentation.  Attention and concentration were also impaired and as a result, a mini-mental status exam (MMSE) on Mr. xx was performed. Mr. xx scored 17 on the MMSE, with major deficits in the recall, calculation, and orientation. Mr. xx was not able to remember any of the 4 items presented after five minutes and he could also not perform serial 7’s or spell the word “read” in reverse, in spite that he has a college degree. He also required prompting using the 3-step command. The MMSE score of 17 indicates severe cognitive impairment for Mr. XX.

Differential Diagnoses

• Major neurocognitive disorder with Lewy bodies: This neurocognitive disorder is characterized by symptoms like attention and concentration impairment; parkinsonian motor signs; rapid eye movement (REM) sleep behavior disorder, and visual hallucinations (Gomperts, 2016). Mr. xx has symptoms such as slowing movement and rest tremor manifesting parkinsonian motor signs; (REM) sleep behavior disorder; and impaired attention and concentration. The symptoms Mr. xx manifests match the symptoms of the neurocognitive disorder with Lewy bodies confirming this diagnosis.
• Major neurocognitive disorder due to Alzheimer’s disease: This disorder is characterized by a progressive decline in cognitive function, a decline in memory, and an indication of causative disease genetic mutation from genetic testing or family history (Dindelegan et al., 2020). However, this disorder is not characterized by REM sleep behavior disorder, and this rules out major neurocognitive disorder due to Alzheimer’s disease for Mr. xx.
• Major frontotemporal neurocognitive disorder (FTNCD): This disorder is characterized by movement disorders; improper social behavior; lack of interpersonal skills and empathy; lack of inhibition; lack of judgment apathy’ repetitive compulsive behavior; changes in personal hygiene; inappropriate feeding habits; and speech and language problems (Young et al., 2018). Mr. xx does not manifest the majority of these symptoms and, this rules out FTNCD for this patient.

Diagnosis

Major neurocognitive disorder with Lewy bodies

Reflection

A comprehensive psychiatric assessment was performed for this patient. The assessment involved collected detailed patient information by interviewing the patient and the wife (caregiver) to collect the correct subjective information. The objective data was collected through physical examination and mental status exam. This enabled us to arrive at the appropriate differential diagnoses. Given another opportunity, I would widely use the latest and best available evidence to research about the comprehensive assessment and the possible differential diagnoses for this patient.

Ethical considerations relevant when evaluating this patient include his decision-making ability and informed consent. The client and the wife need to be informed and educated about the comprehensive psychiatric assessment to ensure an informed consent is obtained from them (Hedge & Ellajosyula, 2016). Additionally, since the patient seems to be impaired cognitively, it would be important to assess his decision-making ability. Comprehensive Psychiatric Evaluation and Patient Case Presentation.

References

Dindelegan, C. M., Faur, D., Purza, L., Bumbu, A., & Sabau, M. (2020). Distress in neurocognitive disorders due to Alzheimer’s disease and stroke. Experimental and therapeutic medicine, 20(3), 2501–2509. https://doi.org/10.3892/etm.2020.8806

Gomperts S. (2016). Lewy Body Dementias: Dementia with Lewy Bodies and Parkinson’s Disease Dementia. Continuum (Minneap Minn), 22(2), 435–463.

Hedge S & Ellajosyula R. (2016). Capacity issues and decision-making in dementia. Ann Indian Acad Neurol, 19(1), S34–S39.

Palermo, G., & Ceravolo, R. (2019). Molecular Imaging of the Dopamine Transporter. Cells, 8(8), 872. https://doi.org/10.3390/cells8080872

Sakamoto, F., Shiraishi, S., Tsuda, N., Ogasawara, K., Yoshida, M., Yuki, H., Hashimoto, M., Tomiguchi, S., Ikeda, M., & Yamashita, Y. (2016). ¹²³I-MIBG myocardial scintigraphy for the evaluation of Lewy body disease: is delayed images essential? Is visual assessment useful? The British journal of radiology, 89(1064), 20160144. https://doi.org/10.1259/bjr.20160144

Young, J. J., Lavakumar, M., Tampi, D., Balachandran, S., & Tampi, R. R. (2018). Frontotemporal dementia: latest evidence and clinical implications. Therapeutic advances in psychopharmacology, 8(1), 33–48. https://doi.org/10.1177/2045125317739818

NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Exemplar

(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.)

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. Comprehensive Psychiatric Evaluation and Patient Case Presentation. 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.

Or

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. This section contains the symptoms that is bringing the patient into your office. 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 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?

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. Comprehensive Psychiatric Evaluation and Patient Case Presentation.

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?

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

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.

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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

NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control. Comprehensive Psychiatric Evaluation and Patient Case Presentation.

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).

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, pseudohallucinations, 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 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.  Comprehensive Psychiatric Evaluation and Patient Case Presentation.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!), 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.).

References

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.

NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation 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:

Diagnostic results:

Assessment

Mental Status Examination:

Differential Diagnoses: Comprehensive Psychiatric Evaluation and Patient Case Presentation.