NURS 6645 Comprehensive Psychiatric Evaluation Note Assignment

NURS 6645 Comprehensive Psychiatric Evaluation Note Assignment

CC (chief complaint):  “I can’t control my urges and it’s causing problems in my life.”

HPI: B.G is a 29-year-old Caucasian female who presents to the clinic with a history of difficulty controlling her impulses. According to her, she has been experiencing this problem for the past year, and it has been causing her a lot of distress. B.G reports that she frequently engages in impulsive behaviors such as overspending, binge-eating, and substance abuse, which have led to financial difficulties and strained relationships with her family and friends. She also states that she feels guilty and ashamed after giving in to her impulses, but finds it hard to resist them. B.G reports that she has tried to control her urges on her own, but has been unsuccessful. She is seeking medical help to address her impulse control disorder and improve her quality of life NURS 6645 Comprehensive Psychiatric Evaluation Note Assignment.

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Past Psychiatric History:

• General Statement: B.G is a generally healthy young adult with no known medical conditions.
• Caregivers (if applicable): currently lives with her partner who is supportive of her seeking medical help.
• Hospitalizations: has never been hospitalized for psychiatric reasons.
• Medication trials: reports no prior trials of psychiatric medications.
• Psychotherapy or Previous Psychiatric Diagnosis: has not been previously diagnosed with a psychiatric disorder or received psychotherapy.

Substance Current Use and History: reports current occasional use of alcohol and marijuana. She denies any history of other substance use.

Family Psychiatric/Substance Use History: reports no known family history of psychiatric or substance use disorders.

Psychosocial History: works as an accountant and reports no recent changes in her work or living situation. She reports a supportive partner and a good relationship with her family. She denies any recent major life stressors.

Medical History:  reports no significant medical history.

• Current Medications: not currently taking any medications.
• Allergies: reports no known allergies.

• Reproductive Hx: reports no pregnancies or history of gynaecological issues. She reports using oral contraceptives for birth control. NURS 6645 Comprehensive Psychiatric Evaluation Note Assignment

ROS:

• GENERAL: reports feeling fatigued and having low energy levels. She denies any recent weight changes.
• HEENT: reports no recent changes in her vision or hearing. She denies any headaches or head trauma.
• SKIN:reports no skin lesions or rashes. She denies any recent changes in her skin.
• CARDIOVASCULAR: denies any chest pain, palpitations, or edema.
• RESPIRATORY: reports no cough, shortness of breath, or wheezing.
• GASTROINTESTINAL: reports occasional nausea, bloating, and constipation. She denies any abdominal pain, diarrhea, or vomiting.
• GENITOURINARY: reports no dysuria, frequency, or hematuria. She denies any vaginal discharge or itching.
• NEUROLOGICAL: reports no recent changes in her mental status or level of consciousness. She denies any seizures or tremors.
• MUSCULOSKELETAL: reports occasional back pain and stiffness. She denies any joint pain or swelling.
• HEMATOLOGIC: reports no history of bleeding disorders or anemia.
• LYMPHATICS: reports no recent lymph node enlargement or tenderness.
• ENDOCRINOLOGIC: denies any history of diabetes, thyroid disorders, or other endocrine problems NURS 6645 Comprehensive Psychiatric Evaluation Note Assignment.

Physical exam: N/A

Diagnostic results: N/A

Assessment

Mental Status Examination:

The patient presents as a cooperative and pleasant young woman with appropriate grooming and hygiene. She appears to be her stated age and her speech is clear and coherent. Her mood is generally depressed and she reports feeling guilty and ashamed about her impulse control issues. Her affect is congruent with her mood and her facial expressions are appropriate. B.G is alert and oriented to person, place, and time. Her attention and concentration are intact, as evidenced by her ability to engage in conversation and answer questions. She has no perceptual disturbances, delusions, or hallucinations. Her thought processes are logical and organized. She denies any suicidal or homicidal ideation. Her cognitive functioning appears to be within normal limits, as evidenced by her ability to recall past events and provide detailed information about her symptoms. Overall, B.G presents with symptoms consistent with an impulse control disorder, and her mental status examination is otherwise within normal limits NURS 6645 Comprehensive Psychiatric Evaluation Note Assignment.

Differential Diagnoses:

Intermittent Explosive Disorder (IED): This is a mental health disorder characterized by recurrent episodes of impulsive and uncontrolled aggressive behavior. Individuals with IED experience intense anger and irritability, often in response to minor triggers, and have difficulty controlling their emotional reactions. These outbursts can lead to physical assaults, destruction of property, and verbal assaults. The DSM-5-TR diagnostic criteria for IED includes recurrent episodes of verbal and/or physical aggression that are disproportionate to the situation, and are not premeditated.. Symptoms of IED may include feelings of tension and irritability before an outburst, a sense of relief or satisfaction after an outburst, and feelings of guilt or remorse following an outburst. IED can have a significant impact on an individual’s relationships, work, and overall quality of life. It is often comorbid with other mental health disorders, including anxiety and depression. In the case of B.G, her symptoms are consistent with a diagnosis of IED. She reports frequent verbal and physical outbursts, which are not premeditated and are often in response to minor triggers. She also experiences feelings of guilt and shame following these episodes. These symptoms align with the DSM-5-TR diagnostic criteria for IED, and support the primary diagnosis.

Borderline Personality Disorder (BPD): This is also a possible diagnosis for B.G, given its symptoms of impulsivity, unstable mood, and difficulty regulating emotions. Individuals with BPD often have intense and unstable relationships, engage in self-destructive behavior, and may experience dissociative symptoms. However, B.G’s symptoms are primarily related to aggression and not to mood instability or identity disturbance, making IED a more likely diagnosis.

Generalized Anxiety Disorder (GAD):This is another possible diagnosis for B.G, given its symptoms of excessive worry and anxiety about a variety of events and activities. Individuals with GAD may experience physical symptoms of anxiety, such as muscle tension, restlessness, and fatigue. However, B.G does not report significant symptoms of anxiety, making GAD a less likely diagnosis NURS 6645 Comprehensive Psychiatric Evaluation Note Assignment.

Case Formulation and Treatment Plan:

B.G reports difficulty controlling her aggressive behavior, which results in verbal and physical outbursts. She experiences intense anger and irritability in response to minor triggers and has low frustration tolerance. These outbursts are often accompanied by feelings of guilt and shame. B.G also reports a history of childhood trauma and stressors in her current life, including financial difficulties and relationship problems.Treatment Plan: The treatment plan for B.G will focus on managing her symptoms of IED, reducing the frequency and severity of her outbursts, and addressing any underlying emotional or psychological issues that may be contributing to her symptoms.

Cognitive-behavioral therapy (CBT) will be the primary mode of treatment, as it has been shown to be effective in managing anger and aggression in individuals with IED. The focus of therapy will be on identifying triggers for B.G’s outbursts and developing coping strategies to manage her emotional reactions. This may include techniques such as cognitive restructuring, problem-solving, and relaxation techniques. In addition to CBT, B.G may benefit from trauma-focused therapy to address the impact of her childhood trauma on her current mental health. This may include techniques such as eye movement desensitization and reprocessing (EMDR) or prolonged exposure therapy. Medication may also be considered as an adjunct to therapy. Selective serotonin reuptake inhibitors (SSRIs) have been shown to be effective in reducing aggression in individuals with IED. However, medication should be carefully monitored and prescribed by a psychiatrist or other qualified healthcare provider. Furthermore, B.G may benefit from stress management techniques, such as exercise, mindfulness meditation, and yoga, to help her manage stress and improve her overall mental health. She may also benefit from couples therapy to address relationship issues with her partner.

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Reflections: If I were to evaluate a similar patient in the future, I would ensure that I obtain a detailed family psychiatric and substance use history to further understand the patient’s risk factors for developing mental health disorders. In addition, I would also inquire about any past or current social stressors and the patient’s support system to gain insight into their social determinants of health.One social determinant of health according to the HealthyPeople 2030 that is relevant to this case is economic stability. B.G’s financial difficulties have been identified as a significant source of stress in her life, which may contribute to her symptoms of IED. In the realm of psychiatry and mental health, economic stability can impact access to mental health services and medication, and can also affect treatment outcomes. Addressing economic instability is crucial to improving mental health outcomes and reducing health disparities in vulnerable populations.One health promotion activity for this patient could be connecting her with local resources such as financial counseling or job placement services to improve her financial stability. A patient education consideration would be to provide her with information on stress management techniques and coping strategies that are accessible and affordable, such as deep breathing exercises or online resources for guided meditation. Addressing economic instability and providing accessible mental health resources are important steps towards reducing health disparities and improving mental health outcomes for individuals like B.G. NURS 6645 Comprehensive Psychiatric Evaluation Note Assignment

 References

American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). (DSM-5). Text Revision.

David, D., Cristea, I., & Hofmann, S. G. (2018). Why cognitive behavioral therapy is the current gold standard of psychotherapy. Frontiers in psychiatry, 4.

Scott, K. M., De Vries, Y. A., Aguilar-Gaxiola, S., Al-Hamzawi, A., Alonso, J., Bromet, E. J., … & De Jonge, P. (2020). Intermittent explosive disorder subtypes in the general population: association with comorbidity, impairment and suicidality. Epidemiology and psychiatric sciences, 29, e138.

Kendrick, T. (2021). Strategies to reduce use of antidepressants. British Journal of Clinical Pharmacology, 87(1), 23-33.

Munir, S., & Takov, V. (2022). Generalized anxiety disorder.

Wilson, G., Farrell, D., Barron, I., Hutchins, J., Whybrow, D., & Kiernan, M. D. (2018). The use of eye-movement desensitization reprocessing (EMDR) therapy in treating post-traumatic stress disorder—a systematic narrative review. Frontiers in psychology, 9, 923.

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: NURS 6645 Comprehensive Psychiatric Evaluation Note Assignment

• 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: NURS 6645 Comprehensive Psychiatric Evaluation Note Assignment

• 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.)NURS 6645 Comprehensive Psychiatric Evaluation Note Assignment

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 behaviours? Any history of self-harm behaviours?NURS 6645 Comprehensive Psychiatric Evaluation Note Assignment

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.)NURS 6645 Comprehensive Psychiatric Evaluation Note Assignment

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)NURS 6645 Comprehensive Psychiatric Evaluation Note Assignment

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)NURS 6645 Comprehensive Psychiatric Evaluation Note Assignment.

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.)NURS 6645 Comprehensive Psychiatric Evaluation Note Assignment.

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)NURS 6645 Comprehensive Psychiatric Evaluation Note Assignment

 

Reviewed hospital records/therapist records for collaborative information; Reviewed PCP report (only if actually available)

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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 NURS 6645 Comprehensive Psychiatric Evaluation Note Assignment

Select a patient for whom you conducted psychotherapy for an impulse control or conduct disorder. 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.

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 in life?
Objective: What observations did you make during the psychiatric assessment?
Assessment: Discuss the patientâ€s mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses in order of highest to lowest priority and explain why you chose them. What was your primary diagnosis and why? Describe how your primary diagnosis aligns with DSM-5-TR diagnostic criteria and is supported by the patientâ€s symptoms.
Plan: Describe your treatment modality and your plan for psychotherapy. Explain the principles of psychotherapy that underline your chosen treatment plan to support your rationale for the chosen psychotherapy framework. What were your follow-up plan and parameters? What referrals would you make or recommend as a result of this psychotherapy session?

Reflection notes: What would you do differently in a similar patient evaluation? Reflect on one social determinant of health according to the HealthyPeople 2030 (you will need to research) as applied to this case in the realm of psychiatry and mental health. As a future advanced provider, what are one health promotion activity and one patient education consideration for this patient for improving health disparities and inequities in the realm of psychiatry and mental health? Demonstrate your critical thinking.
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