Psychiatric Evaluation For Anxiety Essay Assignment

Psychiatric Evaluation For Anxiety Essay Assignment

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 assignment in Weeks 4–10. After reviewing the full details of the rubric, you can use it as a guide. Psychiatric Evaluation For Anxiety Essay Assignment

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!
  

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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-TR diagnostic criteria for each differential diagnosis and explain what DSM-5-TR 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! Psychiatric Evaluation For Anxiety Essay Assignment

Reflect on this case. Include: Discuss 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!), 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.).

(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 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 presents for psychiatric evaluation for anxiety. He is currently prescribed sertraline which he finds ineffective. His PCP referred him for evaluation and treatment. Psychiatric Evaluation For Anxiety Essay Assignment

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. First what is bringing the patient to your evaluation.  Then, include a PSYCHIATRIC REVIEW OF SYMPTOMS.  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-TR 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? Psychiatric Evaluation For Anxiety Essay 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. 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.

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. Psychiatric Evaluation For Anxiety Essay Assignment

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. Psychiatric Evaluation For Anxiety Essay Assignment

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.

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.

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. Psychiatric Evaluation For Anxiety Essay Assignment

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 diagnostic impression selection. You will use supporting evidence from the literature to support your rationale. Include pertinent positives and pertinent negatives for the specific patient case. Psychiatric Evaluation For Anxiety Essay Assignment

 

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.).

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. Psychiatric Evaluation For Anxiety Essay Assignment

Subjective:

CC (chief complaint): “I have these thoughts that I can’t stop thinking about and I have to do certain things over and over again, like wash my hands or check that the door is locked. It’s taking over my life and I’m so anxious all the time.”

HPI: K.T is a  26-year-old Caucasian female who has had symptoms of OCD for the past 5 years. She reports that her symptoms have become more frequent and severe in the past year, and that they interfere with her daily functioning. She describes experiencing obsessive thoughts and behaviors related to cleanliness and organization, and reports feeling distressed and anxious as a result. The patient has previously tried cognitive-behavioral therapy and medication trials with selective serotonin reuptake inhibitors, but has not found relief from these treatments.

Past Psychiatric History:

• General Statement: The patient has a history of OCD, which has been previously diagnosed by a psychologist.
• Caregivers (if applicable): N/A
• Hospitalizations: None
• Medication trials: The patient has previously tried medication trials with selective serotonin reuptake inhibitors, but has not found relief from these treatments.
• Psychotherapy or Previous Psychiatric Diagnosis: The patient has previously tried cognitive-behavioral therapy, but has not found relief from this treatment.

Substance Current Use and History: The patient denies any current or past substance use.

Family Psychiatric/Substance Use History: The patient reports no family history of psychiatric disorders or substance abuse.

Psychosocial History:

Medical History: The patient is currently employed as an office assistant and lives with her husband in a stable home environment. She reports no significant stressors or major life changes in the past year. Psychiatric Evaluation For Anxiety Essay Assignment

 

• Current Medications: None
• Allergies: None

• Reproductive Hx: The patient reports no reproductive health issues.

ROS:

• GENERAL: Denies weight change, fever, chills, or fatigue.
• HEENT: Eyes: Denies vision problems or eye pain. Ears, Nose, Throat: No complaints.
• SKIN: No rashes, lesions, or changes in skin color.
• CARDIOVASCULAR: No chest pain, palpitations, or shortness of breath.
• RESPIRATORY: No cough or difficulty breathing.
• GASTROINTESTINAL: No abdominal pain, nausea, vomiting, or changes in bowel habits.
• GENITOURINARY: No urinary frequency, urgency, or incontinence.
• NEUROLOGICAL: No headaches, dizziness, or tremors.
• MUSCULOSKELETAL: No joint pain or swelling.
• HEMATOLOGIC: No easy bruising or bleeding.
• LYMPHATICS: No swollen lymph nodes.
• ENDOCRINOLOGIC: No heat or cold intolerance, excessive sweating, or changes in appetite or weight.

Objective:

Physical exam: No significant findings on physical examination.

Diagnostic results: The patient was administered the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) to assess the severity of her OCD symptoms. The patient scored 25 on the scale, indicating severe OCD. Psychiatric Evaluation For Anxiety Essay Assignment

Assessment:

Mental Status Examination:

Orientation: Patient is oriented to person, place, and time.

Mood: Patient reports feeling anxious and distressed due to her OCD symptoms.

Affect: Patient’s affect is appropriate to her reported mood.

Speech: Patient’s speech is clear and coherent.

Thought process: Patient’s thought process is logical and organized.

Thought content: Patient reports having obsessive thoughts related to cleanliness and organization. No suicidal or homicidal ideation reported.

Perception: No hallucinatory experiences reported.

Cognition: Patient’s cognition is intact, with no deficits in memory, attention, or executive functioning.

Differential Diagnoses:

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• Obsessive-Compulsive Disorder (OCD) – This is the most likely diagnosis based on the patient’s reported symptoms of obsessive thoughts and behaviors related to cleanliness and organization, as well as the previous diagnosis of OCD by a psychologist. The patient’s score of 25 on the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) also supports a diagnosis of OCD. The DSM-5-TR criteria for OCD include the presence of obsessions or compulsions that are time-consuming or cause significant distress, and the patient meets these criteria (Olatunji & McKay, 2020). This diagnosis is further supported by the fact that the patient has previously tried and failed to find relief from cognitive-behavioral therapy and medication trials with selective serotonin reuptake inhibitors, which are commonly used treatments for OCD. Psychiatric Evaluation For Anxiety Essay Assignment

 

• Generalized Anxiety Disorder (GAD) – This diagnosis could also be considered based on the patient’s reported feelings of anxiety and distress. However, the presence of obsessions and compulsions specifically related to cleanliness and organization, as well as the patient’s previous diagnosis of OCD, support a primary diagnosis of OCD rather than GAD. Additionally, the DSM-5-TR criteria for GAD require the presence of excessive anxiety and worry about a variety of topics for at least 6 months (American Psychiatric Association, 2013).
• Panic Disorder – This diagnosis could be considered based on the patient’s reported feelings of anxiety. However, the patient has not reported experiencing panic attacks, which are a key symptom of Panic Disorder. Additionally, the patient’s symptoms are primarily focused on obsessions and compulsions related to cleanliness and organization, rather than sudden and unexpected panic attacks. The DSM-5-TR criteria for Panic Disorder require the presence of recurrent, unexpected panic attacks and at least one of the attacks has been followed by at least 1 month of concern about having additional attacks or a significant change in behavior related to the attacks (Hofmann & Smits, 2019). The patient does not meet these criteria. Psychiatric Evaluation For Anxiety Essay Assignment

Reflections:

If I could conduct the session over, I would ask the patient more about their past treatment experiences and the specific strategies that were used in cognitive-behavioral therapy to address their OCD symptoms. This would provide a clearer understanding of what has and has not been helpful for the patient in the past, and could inform the development of a more tailored treatment plan.

In terms of legal and ethical considerations, it would be important to obtain the patient’s informed consent for treatment and to respect their confidentiality. Additionally, given the patient’s age and the fact that they are currently employed, it would be important to consider the potential impact of treatment on the patient’s work and daily life, and to involve the patient in decision-making about treatment options.

In terms of health promotion and disease prevention, it would be important to consider the patient’s overall physical and mental health, as well as any potential risk factors. For example, if the patient reports experiencing significant stress at work or in their personal life, addressing these stressors could be an important component of treatment. Additionally, providing the patient with information about self-care strategies, such as stress management techniques or ways to improve their overall physical health, could be helpful in preventing the worsening of their OCD symptoms or the development of other mental health concerns. Psychiatric Evaluation For Anxiety Essay Assignment

Finally, considering the patient’s personal and cultural background could be important in tailoring treatment to meet the patient’s specific needs and preferences. For example, the patient’s cultural beliefs and values may influence their willingness to try certain treatment approaches or their perception of the cause of their OCD symptoms. It would be important to consider these factors and to work with the patient to develop a treatment plan that is culturally sensitive and meets their individual needs.

PATIENTS WITH ANXIETY DISORDERS, PTSD, AND OCD

Complete and submit your Comprehensive Psychiatric Evaluation, including your differential diagnosis and critical-thinking process to formulate primary diagnosis.

Incorporate the following into your responses in the template:

Screening tools. Please incorporate appropriate screening tools into your “objective” section. I would like for each case to incorporate at least 1 relevant screening tool. This is to help familiarize you with the available tools to help with your differential diagnosis. Psychiatric Evaluation For Anxiety Essay Assignment

Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What is 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 with supporting evidence, listed in order from highest priority to lowest priority. Compare the DSM-5-TR diagnostic criteria for each differential diagnosis and explain what DSM-5-TR 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.
Reflection notes: What would you do differently with this client if you could conduct the session over? 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.). Psychiatric Evaluation For Anxiety Essay Assignment