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Comprehensive Psychiatric Evaluation

Comprehensive Psychiatric Evaluation

CC

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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?

 

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