NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template
Assessing and Diagnosing Patients With Mood Disorders
Accurately diagnosing depressive disorders can be challenging given their periodic and, at times, cyclic nature. Some of these disorders occur in response to stressors and, depending on the cultural history of the client, may affect their decision to seek treatment. Bipolar disorders can also be difficult to properly diagnose. While clients with a bipolar or related disorder will likely have to contend with the disorder indefinitely, many find that the use of medication and evidence-based treatments have favorable outcomes.
· Download the Comprehensive Psychiatric Evaluation Template, which you will use to complete this Assignment. Also review the Comprehensive Psychiatric Evaluation Exemplar to see an example of a completed evaluation document.
· By Day 1 of this week, select a specific video case study to use for this Assignment from the Video Case Selections choices in the Learning Resources. View your assigned video case and review the additional data for the case in the “Case History Reports” document, keeping the requirements of the evaluation template in mind.
· Consider what history would be necessary to collect from this patient.
· Consider what interview questions you would need to ask this patient.
· Identify at least three possible differential diagnoses for the patient.
Complete and submit your Comprehensive Psychiatric Evaluation, including your differential diagnosis and critical-thinking process to formulate a primary diagnosis. Incorporate the following into your responses in the template:
· 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 patient’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 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.).
Mood Disorders
Training Title 8 Name: Mrs. Abrianna Tilman Gender: female Age: 27 years old T- 98.6 P- 88 R 18 154/92 Ht 5’1 Wt 230lbs Background: Recently had her first child two months ago. Currently married; stay at home mother after working in community library for 5 years. Grew up with her mother after her parents divorced when she was 16; has two sisters in Troy, Alabama. Completed education through bachelor’s level, majoring in English Literature. No previous suicidal gestures. Brother committed suicide via GSW. She denied drugs/alcohol; brother was addicted to methamphetamines. Hx of HTN-prescribed Trandate 100mg twice daily, admits to missing doses due to forgetting. No legal hx. Allergies: PCN
Transcript of the video
00:00:15OFF CAMERA Mrs. Tilman, your husband is extremely worried about you.
00:00:20MRS. TILMAN Yes, I know that.
00:00:25OFF CAMERA Does coming her bother you?
00:00:25MRS. TILMAN Yes. Yes it does. I’ve never been to a shrink before. I don’t think I need to be here now.
00:00:35OFF CAMERA I’d like to ask you a few questions if that’s ok.
00:00:40MRS. TILMAN Yeah, that should be fine.
00:00:40OFF CAMERA How have you been feeling health wise?
00:00:45MRS. TILMAN Fine. No health problems.
00:00:45OFF CAMERA Sleep?
00:00:50MRS. TILMAN I can’t sleep much. But that’s to be expected.
00:00:50OFF CAMERA How so?
00:00:50MRS. TILMAN The baby. It cries a lot.
00:00:55OFF CAMERA And that wakes you?
00:00:55MRS. TILMAN Well I’m usually already awake.
00:01:00OFF CAMERA You have trouble sleeping?
00:01:00MRS. TILMAN Just falling asleep. Especially after the baby cries.
00:01:05OFF CAMERA What’s the baby’s name?
00:01:10MRS. TILMAN Jessica.
00:01:10OFF CAMERA Beautiful name. How old is she?
00:01:15MRS. TILMAN Two months.
00:01:15OFF CAMERA How has your appetite been lately?
00:01:20MRS. TILMAN I don’t know. It’s not big, but I want to lose weight after the pregnancy.
00:01:25OFF CAMERA You aren’t comfortable with the way you look?
00:01:30MRS. TILMAN I’m terrible. Alright. I look terrible, I feel terrible. My body is bloated. I have lines on my face, bags. I look disgusting.
00:01:45OFF CAMERA What do you do to lose weight?
00:01:50MRS. TILMAN Well, I want to run, but… I don’t get out much.
00:01:55OFF CAMERA Why?
00:01:55MRS. TILMAN Cause I’m stuck at home. I have to take care of the baby, all day long. I guess I should just get used to it. This is my life now all day long, stuck at home with the kid.
00:02:10OFF CAMERA You don’t have a nanny?
00:02:10MRS. TILMAN Who could afford one? Especially with having to pay for the kid.
00:02:15OFF CAMERA Have you said any of this to your husband?
00:02:20MRS. TILMAN To Rick?
00:02:20DR. GREY Uh huh.
00:02:20MRS. TILMAN No. I couldn’t. He’d be so disappointed in me. How could I even tell him that I felt this way. That I wanted out. He comes home from work and… he plays with Jessica. This perfect family.
00:02:50OFF CAMERA How has your relationship been?
00:02:55MRS. TILMAN Not good.
00:02:55OFF CAMERA What’s happened since Jessica was born?
00:03:00MRS. TILMAN It’s not added much. I mean it is my fault. I can’t stop crying. All the time. [she cries] Sometimes I don’t even know who the baby is. And I yell a lot. Things just upset me. Everything and anything he does lately just upsets me.
00:03:35OFF CAMERA For instance?
00:03:40MRS. TILMAN Well… Well the other day he came home and changed her diaper but he threw the dirty diaper in the wrong trash can and he didn’t tie it up in the bag the way he was supposed to.
00:03:55OFF CAMERA And that upset you?
00:03:55MRS. TILMAN Yeah. And I told him, and I was yelling so he started yelling. So yeah. That’s our marriage right now.
00:04:10OFF CAMERA Have you been sexually active since Jessica was born?
00:04:10MRS. TILMAN No. Not really. I have no drive or desire. Rick keeps wanting to but I just… I push him away.
00:04:20OFF CAMERA And how is your social life?
00:04:25MRS. TILMAN Non-existent. I haven’t seen my friends in forever. They came over to see the baby but that’s about it. I might as well get used to it. I can’t go out anymore. She’s too young for a baby sitter, and even then we couldn’t afford one. I had to quit my job.
00:04:55OFF CAMERA Were you forced to quit?
00:05:00MRS. TILMAN No. They gave me maternity leave, but… but I figured this is never going to end. I might as well leave now.
00:05:10OFF CAMERA Do you do anything for yourself? Something to relax, something creative?
00:05:15MRS. TILMAN No. I tried writing. I liked writing but… I don’t know, I… nothing moves me.
00:05:30OFF CAMERA You can’t write now?
00:05:35MRS. TILMAN I have no inspiration, and it’s not fun. I know I’m going to be interrupted soon anyway. Before Jessica, I could write for hours a night. I hated anyone disturbing me. [she cries] Now I can’t have twenty minutes. And you can’t tell a baby to hold on with wanting her lunch. For an hour. When she’s hungry, she’s hungry.
00:06:05OFF CAMERA Do you regret having a child?
00:06:05MRS. TILMAN No. I… I’m just not sure. I’m not sure, okay.
00:06:20OFF CAMERA Are you happy? Does anything give you pleasure?
00:06:30MRS. TILMAN [Shakes her head] No. [she cries]. Look, please, I… I know I’m a mother now. I. [sigh] I don’t know how to put this, I feel terrible. [Cries harder]. I don’t want to be a bad mother. I love my daughter. But I don’t know… I don’t know why I say these things. It’s just really difficult… and Rick, I see Rick and he has this look. It’s this look, its like I know what you’re thinking. It’s like he’s judging me. It’s like he knows I’m not normal. I mean, what’s wrong with me? Sometimes I can’t even hold my own child, I… I, she’s crying and I can’t… I can’t touch her. And when I give her milk it disgusts me. I don’t know what to do. I don’t know what’s wrong with me. I don’t know what’s wrong with me. [She reaches for a tissue]
00:08:15OFF CAMERA Mrs. Tilman, do you have thoughts of suicide or death?
00:08:20[she shakes her head yes]
00:08:25OFF CAMERA Have you acted upon them?
00:08:30MRS. TILMAN [she shakes her head no] No. I couldn’t. I couldn’t do that to Rick or Jessica. And then I feel guilty again. It’s this… this endless cycle. I’m not happy and I want to get out and if I get out, then I would just… I would just… just ruin everyone and that makes me more unhappy.
00:09:05[sil.]
00:09:20SymptomMedia Visual Learning for Behavioral Health www.symptommedia.com
00:09:20END TRANSCRIPT
Important
Informal blogs, internet posts and websites that are not part of a scholarly review process. This includes popular hospital websites (such as MayoClinic.org), Patient facing websites with information designed for the patient, not the provider (such as WebMD, Healthline and MedicineNet, among many others), and UptoDate.com. Information should not be utilized from UptoDate.com since all information is a synthesis of the most up to date literature available. If you wish to use information from UpToDate, use the original sources, not the UpToDate website.
Another student’s work. Regardless of where it is obtained, the use of another student’s written work is never appropriate. This includes use of another student’s work as a “reference”, or exemplar assignment. Templates and examples are often provided in the classroom. If they are not and you would like one, please request this from your instructor.
NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template
Week (enter week #): (Enter assignment title)
Student Name
College of Nursing-PMHNP
NRNP 6635: Psychopathology and Diagnostic Reasoning
Faculty Name
Assignment Due Date
Subjective:
CC (chief complaint):
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
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