Comprehensive Psychiatric Evaluation
CC
26-year-old white female. Individual is A/O x3. Individual reports she was placed on medication during recent inpatient admission to psychiatric facility. Individual reports “it works a little too well. It makes me sleepy.” She reports originally going to the psychiatric facility because she could not sleep. Individual reports being diagnosed with Bipolar disorder. She reports losing 14 pounds within one week. Individual reports taking Gabapentin 600 mg in the morning, 600 mg at noon, and 1200 mg at night, and Abilify 5 mg at night. Individual complains of sleeping too much at night. Individual rates life 8/10 with 10 being total happiness. She denies S/I, H/I. individual reports that she has highs and lows. She reports she tried Lithium during inpatient admission “I had a really bad reaction. I had diarrhea.” DX; Bipolar I disorder (mixed); Mild depression. Plan; Gabapentin 600 mg tablet, 1.5 tablet nightly, Gabapentin 600 mg one tablet twice daily, Aripiprazole 5 mg one tablet nightly. Comprehensive Psychiatric Evaluation
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Mental function
PHQ-9 total core: 4, GAD-7 total score: 6
Vitals
Ht: 5’11”
Wt: 169 lbs
BMI: 23.57
Pain: 0/10
HPI
“Everything hit me like a freight train in January. I could not sleep.” Individual denies childhood trauma.
PMHx
Bipolar disorder
Hallucinations, delusions – Reports hallucinations and delusions when medications were adjusted.
Hyperlipidemia
PSHx
Comments: teeth pulled; cyst cut in back
FHx
Comments: Mother (living) Father (living), skin cancer (mets to brain)
Soc Hx
Alcohol: do not drink
Drug Abuse: No illicit drugs
Tobacco: Never smoker
Ob Preg Hx
Age of menses: 12
Allergies
No known medication allergies
ROS
Psychiatric: (+) change in mood, (-) depression, (-) sadness interfering with function, (+) anxiety, (+) nervousness, (-) sleep disturbance, (-) suicidal/homicidal ideations, (-) hopelessness, (+) worthlessness, (-) delusions, (-) hallucinations
Week (enter week #): (Enter assignment title)
Student Name
College of Nursing-PMHNP, Walden University
NRNP 6635: Psychopathology and Diagnostic Reasoning
Faculty Name
Assignment Due Date
Subjective:
CC (chief complaint): Comprehensive Psychiatric Evaluation
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:
Objective:
Physical exam:if applicable
Diagnostic results:
Assessment:
Mental Status Examination:
Differential Diagnoses:
Reflections:
References
Comprehensive Psychiatric Evaluation and Patient Case Presentation
- Include at least five (5) scholarly resources to support your assessment and diagnostic reasoning.
- Subjective: What details did the patient provide regarding their personal and medical history? What are their symptoms of concern? How long have they been experiencing them, and what is the severity? How are their symptoms impacting their functioning?
- Objective: What observations did you make during the interview and review of systems?
- Assessment: What were your differential diagnoses? Provide a minimum of three (3) possible diagnoses. List them from highest to lowest priority. What was your primary diagnosis, and why?
- Reflection notes: What would you do differently in a similar patient evaluation?
