Comprehensive Psychiatric Evaluation
For this Assignment, you will document information about a patient that you examined at your practicum site, using the Comprehensive Psychiatric Evaluation Note Template provided.
· Present the full complex case study. Include subjective and objective data; assessment from most recent mental status exam; current psychiatric diagnosis including differentials that were ruled out; current psychotherapeutic plan (include one health promotion activity and one patient education strategy you provided); and patient progress toward treatment goals.
· 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.
Therapist Initial Visit
CC
Referred by another doctor to be seen by a psychotherapist. Was attacked by a resident Nursing and Rehabilitation about a year ago. Resident was in the locked unit. Resident asked her to help him change. Punched her in her face, down her arm, down her back. She was 5’3″ and 110# at that time. Nurse was on break. Coworker on the other side of the glass. He called her a n _ _ _ _ r. Worked the 11 p.m. to 7 a.m. shift.
Has seen a neurologist, had a severe concussion. Has post-concussion syndrome, dizziness. Has tingling in her fingers, wrist. The side of her face also has continuing pain. Has sharp pain in her left ear.
Had an MRI and CT scan. Was found to have Venus thoracic outlet syndrome.
Workers Comp, Thomas Swonger, works for Davies Claims Solutions, and is downplaying her continuing symptoms. Car stopped working, so she could not get to physical therapy. Was discharged, rather than having transportation arranged.
Was seen by a surgeon, who states that the condition may be able to be corrected by surgery.
She is not able to lift more than 10 pounds. Her cat died in August 2024. He was a “support animal.” At that time she was in a toxic relationship.
Her children are aged 5 and 7 years. They are in Kindergarten and 1st grade.
Speech is also effected by the incident.
ENT doctor diagnosed assymetric hearing loss, left ear.
She is out of work currently until after she has surgery. Neurologist had cleared her to go back to work. He put her back into the care of an orthopedic doctor. She could not lift clients, and was put on light duty. Residents became angry with her for sorting out their closets, which was the light duty.
Resident who assaulted her was still in her workplace.
She is working with an attorney on the case. Resident who hurt her was never supposed to be in the rehab in the first place.
She helps herself by attending church and being involved with the photography team, young adult team.
Didn’t want to bring this up, but she attempted suicide at age 12-17. Tried cutting, pills, hanging. Didn’t want to be here anymore. Did not see a future for herself.
Has tachycardia, and takes meds for that. Has thyroid disease, she learned 3 years ago, and is also medicated for that.
Has had dreams/premonitions.
HPI
Patient presents for initial evaluation.
PsychHx
Anxiety and depression due to long standing relationship, emotionally, verbally and physically abusive. Stalked her after they broke up. She had 2 children from this relationship. Primary custody with client. Supervised visitation every other weekend, with client’s mother being the supervisor.
PsychFHx
Oldest sister has bi-polar disorder. She, and mother, were abused by mother’s previous husband. Mother felt she was “attention-seeking.”
In childhood her sister “tried to kill me.” Pillow over her face, threatened with a hammer, iron thrown at her, etc.
“Hates” being around her family. Feels protective of her 2 daughters, and of herself. She is afraid that mother will try to take her children, as she had her nephew.
PsychSHx
The patient was born in Frankfurt, Germany. Father was in the service.. The patient is the third of three. Throughout school the patient had been teased by friends. The patient completed and CNA, Certified Medical Assistant, would like to be a midwife in the future
Medications
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
Client has experienced a high degree of trauma from a workplace incident about a year ago. She is working with an attorney to file a Worker’s Compensation claim.
DSM-5
Post-traumatic stress disorder
Depression and anxiety
Assessment
Client would benefit from ongoing individual therapy, especially as she deals with the Workers Comp claim from 1 year ago.
Collepals.com Plagiarism Free Papers
Are you looking for custom essay writing service or even dissertation writing services? Just request for our write my paper service, and we'll match you with the best essay writer in your subject! With an exceptional team of professional academic experts in a wide range of subjects, we can guarantee you an unrivaled quality of custom-written papers.
Get ZERO PLAGIARISM, HUMAN WRITTEN ESSAYS
Why Hire Collepals.com writers to do your paper?
Quality- We are experienced and have access to ample research materials.
We write plagiarism Free Content
Confidential- We never share or sell your personal information to third parties.
Support-Chat with us today! We are always waiting to answer all your questions.
