Comprehensive Psychiatric Evaluation Assignment

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Comprehensive Psychiatric Evaluation Assignment

 

Submit a Comprehensive psychiatric evaluation on an adult and aging adult with a mental illness.  Give a short synopsis of the case and why the patient has come to see you.

Comprehensive Psychiatric Evaluation

Complete and submit an outstanding Initial Psychiatric Evaluation note from an actual patient you cared for during practicum experience.

Attached is an example of what is needed for the paper and a blank copy to fill in the information. This must be done on a psych patient. Thanks

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Source of Information

 

 Patient himself (historian)
CASE PRESENTATION (Presenting features, medical/social/family history of Mental illness.)

 

 Patient LM is a 63-year-old Caucasian male still working as a truck driver. He lives alone in the countryside after divorcing his wife five years ago. They did not have any children. Lately he has been having financial problems and lack of a social support system. He presented with complaints of unexplained sadness, low self-esteem, insomnia, and thoughts about death and dying. He refutes any family history of mental illness. He also denies a personal history of mental illness.
Demographics should include: age, sex, who they live with, who they are accompanied by for your interview, who referred them to you. Patient LM is a male Caucasian who is 63 years old and lives alone in a trailer home in the countryside. He was referred for psychiatric evaluation by his PCP. When he came he was unaccompanied.Comprehensive Psychiatric Evaluation Assignment
Chief Complaint of Patient: Patient’s words “Unexplained sadness, low self-esteem, insomnia, and thoughts about death and dying.”
History of Present Illness The client, who is a truck driver in his 63rd year, has the aforementioned concerns. He disputes having ever had the concerns that started around three months ago. The location of manifestations is within the mind. The signs are ever-present. Usually, the symptoms are debilitating and enduring. Two things that aggravate loneliness are family-related thoughts. There is some relief in being around coworkers. Both during the day and at night, the manifestations are visible. He rates the severity of his symptoms at seven out of ten.
Current Medications He is currently not on any medications.
Past Psychiatric History He denies any past psychiatric history.
Past Psychiatric Medications He has never been put on any medication trials for psychiatric illness.
Substance Use/Abuse He denies any substance abuse including etoh and tobacco.
Medical History He had an elevated HbA1c of 6.7% three months ago. He is to get another test this month and he will be confirmed type II diabetic if it is also high. He has no other medical conditions.
Allergies NKDA.
Family History Both of his parents are deceased. His father died at 70 in a plane crash, while his mother died at 62 in a drowning accident. The family had no history of chronic medical conditions.
Psychiatric and Addiction History He denies any history of psychiatric illness or any addiction history.
Developmental and Social History He met all his childhood developmental milestones normally. He also got all his vaccinations. Socially he has few friends who are work colleagues. He never drinks or smokes and does not usually go out.
MSE: Appearance and behavior
   
   
  Mood
  Affect
  Thought content
  Thought process
  Perceptual disturbances
  Cognition
  Abstract Reasoning
  Concentration
  Impulsivity
  Insight
  Judgment
  Threat to self or others
  Motivation

Strength and Weakness

 
  Motor activity
  Speech
Client is a 63-year-old Caucasian male who is alert and oriented in all respects. His speech is clear and goal-oriented. He appears well groomed and does not show any mannerisms or tics. There is psychomotor retardation. His mood is “sad” and affect dysphoric. Denies HI but accepts having SI. Denies delusions and hallucinations. Abstraction and memory are good. Insight and judgment are intact.

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DIAGNOSTIC TESTS
Lab tests are all normal. PHQ-9 however is positive for moderate depression.
CASE FORMULATION

 

 The patient’s symptoms are suggestive of a DSM-5-TR diagnosis of MDD.
DIFFERENTIAL DIAGNOSIS (with rationale based on DSM 5 and findings

 

 Dysthymia or Persistent Depressive Disorder: 300.4 (F34.1)

There must be symptoms such as fatigue, low self-esteem, poor appetite, poor attention, insomnia, and others (APA, 2022; Boland et al., 2021).

Bipolar I Disorder, Major Depressive Episode: 296.52 (F31.32)

To be diagnosed with bipolar depression, an individual must exhibit signs of the illness. Only after experiencing a manic episode once may a person be diagnosed with bipolar I disorder, which is typified by the occurrence of opposing emotions twice (APA, 2022)Comprehensive Psychiatric Evaluation Assignment.
DIAGNOSIS: (Include ICD 10 codes)

 

 Major Depressive Disorder (MDD): 296.22 (F32.1)

Some people struggle with sadness, worry, and sleeplessness; as a result, they often withdraw and prefer to be by themselves. They become dysfunctional as a result in terms of their employment, interpersonal interactions, and self-care (APA, 2022; Boland et al., 2021).
Treatment Plan:

 

Pharmacology

Psychotherapy

Referrals

Patient Education

 

 ·         Sertraline (Zoloft) 100 mg orally OD (Stahl, 2020).

·         Cognitive behavioral therapy (CBT) weekly for 12 weeks (Wheeler, 2020).

·         Referral to local community social support organizations.

·         Educated on importance of medication compliance and medication side effects.
FOLLOW-UP

 

 Next follow-up set after four weeks.
   

References

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

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

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.

Patient himself (historian)
Patient LM is a 63-year-old Caucasian male still working as a truck driver. He lives alone in the countryside after divorcing his wife five years ago. They did not have any children. Lately he has been having financial problems and lack of a social support system. He presented with complaints of unexplained sadness, low self-esteem, insomnia, and thoughts about death and dying. He refutes any family history of mental illness. He also denies a personal history of mental illness. Comprehensive Psychiatric Evaluation Assignment
Patient LM is a male Caucasian who is 63 years old and lives alone in a trailer home in the countryside. He was referred for psychiatric evaluation by his PCP. When he came he was unaccompanied.
“Unexplained sadness, low self-esteem, insomnia, and thoughts about death and dying.”
The client, who is a truck driver in his 63rd year, has the aforementioned concerns. He disputes having ever had the concerns that started around three months ago. The location of manifestations is within the mind. The signs are ever-present. Usually, the symptoms are debilitating and enduring. Two things that aggravate loneliness are family-related thoughts. There is some relief in being around coworkers. Both during the day and at night, the manifestations are visible. He rates the severity of his symptoms at seven out of ten.
He is currently not on any medications.
He denies any past psychiatric history.
He has never been put on any medication trials for psychiatric illness.
He denies any substance abuse including etoh and tobacco.
He had an elevated HbA1c of 6.7% three months ago. He is to get another test this month and he will be confirmed type II diabetic if it is also high. He has no other medical conditions.
NKDA.
Both of his parents are deceased. His father died at 70 in a plane crash, while his mother died at 62 in a drowning accident. The family had no history of chronic medical conditions.
He denies any history of psychiatric illness or any addiction history.
He met all his childhood developmental milestones normally. He also got all his vaccinations. Socially he has few friends who are work colleagues. He never drinks or smokes and does not usually go out. Comprehensive Psychiatric Evaluation Assignment

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Client is a 63-year-old Caucasian male who is alert and oriented in all respects. His speech is clear and goal-oriented. He appears well groomed and does not show any mannerisms or tics. There is psychomotor retardation. His mood is “sad” and affect dysphoric. Denies HI but accepts having SI. Denies delusions and hallucinations. Abstraction and memory are good. Insight and judgment are intact.
Lab tests are all normal. PHQ-9 however is positive for moderate depression.
The patient’s symptoms are suggestive of a DSM-5-TR diagnosis of MDD.
Dysthymia or Persistent Depressive Disorder: 300.4 (F34.1)

There must be symptoms such as fatigue, low self-esteem, poor appetite, poor attention, insomnia, and others (APA, 2022; Boland et al., 2021).

Bipolar I Disorder, Major Depressive Episode: 296.52 (F31.32)

To be diagnosed with bipolar depression, an individual must exhibit signs of the illness. Only after experiencing a manic episode once may a person be diagnosed with bipolar I disorder, which is typified by the occurrence of opposing emotions twice (APA, 2022)Comprehensive Psychiatric Evaluation Assignment.
Major Depressive Disorder (MDD): 296.22 (F32.1)

Some people struggle with sadness, worry, and sleeplessness; as a result, they often withdraw and prefer to be by themselves. They become dysfunctional as a result in terms of their employment, interpersonal interactions, and self-care (APA, 2022; Boland et al., 2021).
  • Sertraline (Zoloft) 100 mg orally OD (Stahl, 2020).
  • Cognitive behavioral therapy (CBT) weekly for 12 weeks (Wheeler, 2020).
  • Referral to local community social support organizations.
  • Educated on importance of medication compliance and medication side effects.
Next follow-up set after four weeks.