Comprehensive Psychiatric Evaluation Note

Select a patient for whom you conducted psychotherapy for a mood disorder during the last 4 weeks. Create a Comprehensive Psychiatric Evaluation Note on this patient using the template provided 

• 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 patient’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 patient’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.

 

 

 

 

 

Below is a patient: 30 years female.

Therapist Initial Visit

CC

Has been in counseling her whole life.  Was with a therapist all along, and then stopped in 2021-2022.  Has learned a lot along the way, but wants to get back into it.  Her biggest struggle has been a 12-year relationship with Josh, her now-husband, which “may, or may not be a healthy one.”  

Husband broke his leg a few weeks ago.  Couple’s counseling has been put on hold.  The way we have treated each other has not been healthy.  Had one session with a therapist, then they got into a fight that turned physical.  She had advised her to leave, which she did not.  They have a child, who will be 6 in April 2025.  Is almost 100% estranged from all family members.  When she was 23, her father died of a heart attack.  Client got the proceeds of a life insurance policy he had taken out on himself.  Father had “toxic masculinity,” by her mother’s description.  He was a Marine Corps veteran and served in Vietnam.  Does not remember much from her childhood.  Father had visitation with her, and behaved poorly.  Mother had lied to her about father not wanting to see her, and that father had molested her.  Mother has BPD, and is not in therapy.  She is going to be about 68 years old.  Mother tends to blame others for everything that has gone wrong.  Mother has recently moved,  again.  She fell outside, and was there for 24 hours, and then was hospitalized for about 2 weeks.  Mother had been rotating staying with her, and her 2 sisters.  Left for Florida when client was 19, leaving client pregnant with her then-boyfriend, and now-husband.  Has been isolated from 2 sisters.  Will get into arguments with husband about “something she misheard,” etc.  Husband broke his leg after telling client “you’re just like your mother,” which then cause him to call her a b****.  He spit at her, client walked out to her car and wanted to  “just breathe.”  He came out, beat her to her car, and sat in the car himself.  She went back inside, and locked the door behind her, locking him out.  He broke his foot coming up the steps to come back inside, as he had been in sock feet, and the steps were slick.

 

When they’ve had arguments in the past, he will sometimes tell her “go to your room.”  She told him that she was not his child, and that she could go into any room she wants to, in that it is their home.  Their relationship has been bad for the entire 12 years they’ve been together.  They were happily married for about a month.  Client went through his phone to see who he was cheating on her with.  His excuse is that she does not give her “enough affection.”  She states that she does not “crave sex,” which is different from how her husband’s sex appetite is.

HPI

Patient presents for initial evaluation.

PsychHx

The patient has seen Has had a therapist in the past, as well as a prescriber.

PsychFHx

Mother, 2 sisters have depression.  Oldest sister quit taking her diabetes medicine and lost her foot.

 

Mother also has BPD.  Mother’s grandmother died by suicide.

 

Mother has been hospitalized in an in patient psych facility when client was 16, after she had put a gun to client’s head when she learned client was being sexually active.

PsychSHx

The patient was born in VA. Moved around her whole life, FL, GA.. The patient is the third of three. Throughout school the patient had a few friends. She is still in touch with 2 friends from high school.  High school and Was on the AB honor roll until 10th grade. Was always difficult to concentrate. When she graduated she had her medical assistant certification..

Medications: Is not on any medications currently.  Previously took Prozac prescribed by her PCP.  Saw a psychiatrist previously, and was prescribed other meds.  She states that she will sign a release to request records.

 

MSE

The patient’s speech was normal, sharing conversation with normal laryngeal efforts. Appropriate mood and affect were seen on exam. Thought processes were logical, relevant, and thoughts were completed normally. Thought content was normal with no psychotic or suicidal thoughts. The patient’s judgement was realistic with normal insight into their present condition. Mental status included: correct time, place, person orientation, normal recent and remote memory, normal attention span and concentration ability. Language skills included the ability to correctly name objects. Fund of knowledge included normal awareness of current and past events.

Tests

None at the present time.

Psych Impression

The patient is a 30 year old female who presented with anxiety symptoms and depression.

DSM-5

Depression, anxiety