psychiatric evaluation of a patient with major depressive disorder The psychiatric evaluation of a patient with major depress

Psychiatric Evaluation (AKA Psychiatric History and Physical)

IMPORTANT: Notes are to represent realistic patient with * Mayor Depression Disorder*

These Psych Evals will serve to stimulate discussion, questions, and critique by peers and instructors. Psych Evals are to be posted in weeks 3, 7, and 11. A meaningful response is one that demonstrates critical thought. Refer to the Carlat, Zuckerman, and Kaplan & Sadock (Ch. 5) texts for assistance.

The evaluation is to be read by the clinical preceptor. Please include additional information in italics, for instance, what you may have done differently than your preceptor, or in addition to what was done.

Purpose: The psychiatric evaluation is designed to gather necessary information to assess the client’s condition as well as to begin establishing a therapeutic advanced practice psychiatric mental health nurse – client relationship. The information gathered during this process will allow the advanced practice psychiatric mental health nurse to develop a diagnosis from which a precise treatment plan is prescribed.

Format should be in the H & P format outlined below. Grading rubric is also below:

H & P FORMAT: (Note: This example is not exhaustive and yours must include additional data such as elaboration of rationale, neurobiology, or other information important for an academic exercise but not necessarily appropriate for a clinical document in practice.)

DEMOGRAPHIC INFORMATION

IDENTIFYING INFORMATION: The patient is a (age, marital, ethnicity, gender) who presents today for a psychiatric eval (reason/referral). Sources of information for this evaluation include pt report, collateral info from.., available old records. The patient was/was not able to give an account of his/her activities/life events/symptoms in a chronological order.

SUBJECTIVE DATA (what the patient says to yo)

CC:

HISTORY OF PRESENT ILLNESS: (SUBJECTIVE).

Should use the OLDCARTS acronym when trying to elicit characteristics of symptoms.

Remember to include pertinent negatives.

HPI MUST contain validation of diagnoses. Include your pertinent review of systems (ROS) here. You do not need to do an exhaustive review, only what is pertinent to the patient’s CC. Frequent symptoms that are reviewed in a psych eval are constitutional, neurological. Remember that the ROS is SUBJECTIVE. This is not the place for assessment findings ie. Lungs clear, BS present all 4 quad, skin is clear, appears to be responding to internal stimuli, etc…

PAST PSYCHIATRIC HISTORY:

Be sure to include previous treatment, response to treatment, and explore the seriousness and context of self harm or suicide attempts. Ask about hospitalizations or partial hospitalizations. If they have been diagnosed with psychiatric illness before, ask what type of provider made the diagnosis and why. This helps you understand the patient’s insight and understanding.

Psychotherapy

Hospitalizations

Suicide attempts

PREVIOUS PSYCHIATRIC MEDICATIONS: Question carefully about length of trials, dose, why d/c

CURRENT MEDICATIONS:

SUBSTANCE USE/ ADDICTIVE BEHAVIORS: If + is a higher risk for suicide. First use and circumstances surrounding use, consequences of use (social, legal, economic, relational, health), last use, pattern, CAGE- Cut down-Annoy-Guilt-Eyeopener. Detox/Rehab? How do they handle stress? How often is use, how much, what is the most you did in one day? Be wary of denial/minimization. Any withdrawal S&S? Ask specifically about classes of drugs , illicit and/or prescribed (marijuana, ETOH, stimulants like cocaine, meth, or Ritalin, opiates, synthetics, bath salts, designer drugs, and non controlled like gabapentin, Seroquel, or artane), nicotine, or caffeine (also comes in pill form) and route (“have you ever snorted anything? Injected anything? Taken pills that were not prescribed to you or taken your prescription other than as directed?” Routes include insufflation (snorting) IV, oral, sublingual, transdermal, anal, or vaginal).

Inquire about eating, spending, gaming, gambling patterns. May also begin to inquire about sexual habits.

FAMILY PSYCHIATRIC HISTORY:

Completed suicides

Good response to meds? If yes, which ones?

Dx by psych or self diagnosed?

MEDICAL HISTORY: Head injury, seizures, EEG, CT scan, review of pertinent labs, Current Medical Problems, chronic illnesses (lupus, fibromyalgia, arthritis, parkinsons, thyroid issues, cardiac disease, HTN, diabetes, cancer) any meds that have caused s&s? New onset of illness that causes stress? Last period, pregnancy test? Eating disorders? Sexual history

Medical Illnesses

History of Med Illness

Surgical history

Allergies

PSYCHOSOCIAL:

Ability to work and love. (work=ability to structure daily activities, meet expectations, relate adequately to peers and supervisors, take on level of responsibility. Long term relationship=ability to attend to others needs, control impulses, make a commitment.)

Childhood/developmental history, family of origin, siblings, birth order, relational status, marital status-how long, children, housing situation, education, employment, abuse, religious/spiritual beliefs, legal(consider antisocial or substance abuse if extensive)

Born and raised where/by whom/siblings/relationship status

Education/performance

Living situation

Marriage/relationships

Children

Employment

Legal

Abuse

ASSETS/STRESSORS:

OBJECTIVE DATA

MENTAL STATUS EXAM: (OBJECTIVE).

Must be in narrative form.

Include all elements and be as descriptive as possible. Please refer to Kaplan and Sadock text, Ch. 5, pgs. 201-205 and the Carlat or Robinson texts.

Mental Status Exam Elements- All Borderline Subjects Are Tough Troubled Characters

A- Appearance

Height, build, hair color, style, facial hair, body modifications, facial features, scars, grooming, hygiene, odors, clothing, make-up, impression of general appearance and memorable aspects.

B- Behavior

Attitude

Motor activity

S- Speech

General quality

Fluency

Amount

Rate

Tone

Volume

Prosody

Spontaneity or Latency

A- Affect

Qualities of Affect

Stability

Appropriateness

Range

Intensity

Mood as defined by patient. Usually in quotation marks

T- Thought process

Flow and processing of thought. Examples:

Circumstantiality

Clang associations

Fight of ideas

Perseveration

Thought blocking

T- Thought content

Suicidal ideation (SI), Homicidal ideation (HI), Violent ideation (VI). If + comment on intent, plan, and preparation

Psychotic ideation or perceptual disturbances. Examples:

Delusions or hallucinations

Obsessional thoughts

Compulsions

Ideas of reference

Paranoia (suspiciousness)

Significant themes related to diagnosis

C- Cognitive exam – consider educational attainment when interpreting results.

Alertness

Orientation

Concentration

Memory (long and short term)

Calculation

Fund of knowledge

Abstract reasoning

Insight

Judgment

PHYSICAL EXAM: (VS, HT, WT, LABWORK AND OTHER DIAGNOSTICS)

This section will vary in scope dependent on the setting.

DIFFERENTIAL:

DIAGNOSTIC IMPRESSION WITH FORMULATION:

RISK ASSESSMENT:

RECOMMENDATIONS AND PLAN WITH GOALS AND RATIONALES WITH NEUROBIOLOGY:

When providing treatment recommendations, be as holistic and comprehensive as possible. When describing rationales for these recommendations be as specific as possible. It is not sufficient to explain that a treatment is FDA indicated and then to outline the mechanism of action of the drug. Explain why you (or your preceptor) chose a particular drug or treatment in lieu of another. For instance, why escitalopram instead of citalopram or fluoxetine, or sertraline, etc…?

Remember to include all information that was actually done but also include, in italics, other or additional actions you would have taken or things you would have done differently.

Grading Rubric for Psychiatric Evaluations and Psychiatric Case Presentations

Category	Excellent
Demographic Data	5 Includes identifying information including initials, age, gender, ethnicity. Primary source of information and reliability as well as reason for referral and patient understanding of referral are clear.
Subjective Data History of Present Illness (HPI)	20 CC is clear, concise and verbatim from pt. HPI is thorough yet concise and provides a chronological account of symptoms and contextual factors that are sufficiently descriptive (oldcarts) to validate Dx per DSM-5 criteria. All pertinent negatives are included. A longitudinal course of illness is clear. Current psychiatric medications and response are included.
Past Psychiatric History	5 PPH contains all previous treatment including previous Dx, hospitalizations, outpatient treatments, suicide attempts, self-harm, and previous medications with detailed trial and response history. Pertinent negatives are also included.
Substance Use History	5 Complete substance use history is documented. Pertinent negatives are clear evidenced by appropriate pt. responses ie. “denies”. Age of onset, duration, frequency/pattern of use, route of administration, last use, consequences of use. Not limited to illicit substances. Inclusive of addictive behavioral patterns.
Past Medical History and Review of Systems (ROS)	5 Medical history includes previous and current medical problems, surgeries, and allergies. ROS is germane to the presenting psychiatric problems and is free from objective assessment data ie. “lungs clear” “BS present”.
Family History Psychosocial and Developmental History	10 Family Hx includes identified relational status with current or historical psych illness, treatments, responses, suicides, or self-harm. Indication if biologically related. Dev’t Hx includes info regarding family of origin, siblings, birth order, family dynamics, relational patterns and status, educational, employment, abuse, spirituality, legal, military. Dev’t milestones for child & adolescents are included
Objective Data Mental Status Exam Physical Exam (as appropriate) vital signs, height, weight, labs or other relevant diagnostics.	15 MSE contains all elements as outlined in addendum.. Is in narrative form and effectively and vividly describes the patient’s presentation. Concrete examples of all assessment results are included ie. “able to correctly interpret 2/3 simple proverbs” to validate documentation of “abstract thought intact”.
Assessment	10 Differential is pertinent to S&S, formulation contains evidence of critical thought and subject knowledge, and reasonable diagnoses are made per DSM-5. Clearly met criteria for diagnoses tendered are explicit in the HPI description and substantiated with the MSE.
Plan	15 Evidence-based treatment plan is presented with detailed rationales. Level of detail reflects the student’s ability to choose treatments based not only on FDA approval or current evidence but also the nuances and unique characteristics of each. Treatment plan is holistic and comprehensive. There is strong evidence of the student’s synthesis of information and critical thought.
Writing, Support, APA	5 The format is consistent with the example provided in the course. Strong, recent (5-7 years), scholarly, peer- reviewed support of topics. No grammar, spelling, and punctuation errors. Writing mechanics are consistent with formal scholarly work. No errors in APA style based upon the required APA manuals listed on the course syllabi.

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Rubric Addendum

Mental Status Exam Elements- All Borderline Subjects Are Tough Troubled Character

A- Appearance

Height, build, hair color, style, facial hair, body modifications, facial features, scars, grooming, hygiene, odors, clothing, make-up, impression of general appearance and memorable aspects.

B- Behavior

Attitude

Motor activity

S- Speech

General quality

Fluency

Amount

Rate

Tone

Volume

Prosody

Spontaneity or Latency

A- Affect

Qualities of Affect

Stability

Appropriateness

Range

Intensity

Mood as defined by patient. Usually in quotation marks

T- Thought process

Flow and processing of thought. Examples:

Circumstantiality

Clang associations

Fight of ideas

Perseveration

Thought blocking

T- Thought content

Suicidal ideation (SI), Homicidal ideation (HI), Violent ideation (VI). If + comment on intent, plan, and preparation

Psychotic ideation or perceptual disturbances. Examples:

Delusions or hallucinations

Obsessional thoughts

Compulsions

Ideas of reference

Paranoia (suspiciousness)

Significant themes related to diagnosis

C-Cognitive exam – consider educational attainment when interpreting results.

Alertness

Orientation

Concentration

Memory (long and short term)

Calculation

Fund of knowledge

Abstract reasoning

Insight

Judgment

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