COMPREHENSIVE PSYCHIATRIC EVALUATION NOTE AND PATIENT CASE PRESENTATION
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COMPREHENSIVE PSYCHIATRIC EVALUATION NOTE AND PATIENT CASE PRESENTATION
Psychiatric notes are a way to reflect on your practicum experiences and connect them to the didactic learning you gain from your NRNP courses. Comprehensive psychiatric evaluation notes, such as the ones required in this practicum course, are often used in clinical settings to document patient care.
For this Assignment, you will document information about a patient that you examined in a group setting during the last 4 weeks, using the Comprehensive Psychiatric Evaluation Note Template provided. You will then use this note to develop and record a case presentation for this patient.
BELOW IS THE REQUIRED READING—————————————–
LEARNING RESOURCES
Required Readings
American Group Psychotherapy Association.Links to an external site. (2007–2020). Practice guidelines for group psychotherapy. https://www.agpa.org/home/practice-resources/practice-guidelines-for-group-psychotherapy
American Psychiatric Association.Links to an external site. (2020). Clinical practice guidelines. https://psychiatryonline.org/guidelines
Carlat, D. J. (2017). The psychiatric interview (4th ed.). Wolters Kluwer.
Chapter 23, “Assessing Mood Disorders I: Depressive Disorders”
Chapter 24, “Assessing Mood Disorders II: Bipolar Disorders”
MeditrekLinks to an external site.
https://edu.meditrek.com/Default.html
Note: Use this website to log into Meditrek to report your clinical hours and patient encounters.
National Institute for Health and Care ExcellenceLinks to an external site.
https://www.nice.org.uk/
U.S. Department of Veterans Affairs. (2020). VA/DoD clinical practice guidelines.Links to an external site. https://www.healthquality.va.gov/
PLEASE FIND BELOW THE TOPIC OF THE PAGE AND THATS WHAT YOU NEED TO READ AND DISCUSS————————–
30year old African American female came in because of being anxious and not eating well.
SAMPLE ANSWER
Comprehensive psychiatric evaluation note and patient case presentation
Patient Information:
Patient: Ms. J
Age: 30 years
Gender: Female
Ethnicity: African American
Chief Complaint: Anxiety and poor appetite
History of Present Illness: Ms. J is a 30-year-old African American female who presented to the clinic with complaints of anxiety and poor appetite. She reports feeling nervous and on edge for the past two weeks. She also reports having trouble sleeping and concentrating. She has noticed a significant decrease in her appetite and has lost about five pounds in the last two weeks. She denies any suicidal or homicidal thoughts.
Past Psychiatric History: Ms. J has no prior psychiatric history, and she denies any prior mental health treatment.
Medical History: Ms. J has a history of hypertension, for which she takes lisinopril.
Family History: Ms. J’s mother has a history of depression, and her grandmother had bipolar disorder.
Social History: Ms. J is currently unemployed and lives with her husband and two children. She reports no history of substance abuse.
Mental Status Examination:
Appearance: Ms. J is a well-groomed African American female. She is appropriately dressed for the weather.
Mood and Affect: Her mood is anxious and apprehensive. Affect is reactive and appropriate.
Speech: Ms. J’s speech is normal in rate and volume. She does not exhibit any evidence of a thought disorder.
Thought Content: No evidence of delusions or hallucinations.
Cognition: Ms. J is alert and oriented to time, place, and person. Attention and concentration are mildly impaired. Memory is intact.
Insight and Judgment: Ms. J has fair insight into her situation and poor judgment.
Diagnosis:
Ms. J meets the criteria for generalized anxiety disorder (GAD) based on her history of anxiety, poor appetite, and difficulty sleeping for the past two weeks. She also has a family history of psychiatric illness, which increases her risk for developing anxiety disorders.
Treatment Plan:
I will discuss treatment options with Ms. J, which include psychotherapy, medication, or a combination of both. I will also provide education on stress management techniques and encourage healthy eating and exercise habits. Given her mild cognitive impairment, I will consider starting Ms. J on an SSRI medication such as sertraline or fluoxetine. I will also refer her to a therapist for cognitive-behavioral therapy to address her anxiety.
Case Presentation:
Ms. J is a 30-year-old African American female with a chief complaint of anxiety and poor appetite. She reports feeling anxious and on edge for the past two weeks and has noticed a significant decrease in her appetite. Her mood is anxious and apprehensive, and her affect is reactive and appropriate. She has no prior psychiatric history and takes lisinopril for hypertension. Her family history is positive for depression and bipolar disorder. She is unemployed, lives with her husband and two children, and denies any history of substance abuse. I have diagnosed her with generalized anxiety disorder and plan to start her on an SSRI medication and refer her for cognitive-behavioral therapy to address her anxiety.
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