Comprehensive Psychiatric Evaluation Note And Patient Case Presentation Paper

Comprehensive Psychiatric Evaluation Note And Patient Case Presentation Paper

Subjective: CC (Chief complaint):

My daily drinking is the main reason I am here. It is making me feel like an absent parent and is having an impact on my family. If I want to provide a better existence for my loved ones, I need to learn how to cope with traumatic experiences and keep my negative thoughts in check.

HPI:

1. G., a 45-year-old male, presents with daily alcohol abuse that is impacting his family life negatively. His sexual activity decreases, he feels emotionally distant, and he is neglected. Verbal abuse in the family and treatment for depression and alcoholism are all part of the patient’s history. Emotional and mental health: stable, no hallucinations, cooperative. No further issues have been identified by the thorough mental evaluation. Getting well from trauma, learning to cope, and avoiding recurrence are A. G.’s goals. Comprehensive Psychiatric Evaluation Note And Patient Case Presentation Paper
   Past Psychiatric History:

General Statement: Depression, alcoholism, anxiety, and post-traumatic stress disorder (PTSD) are all parts of A. G.’s past psychiatric history. He stopped smoking eighteen years ago and is now using therapy to get through these concerns.

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Caregivers: No caregivers currently.

Hospitalizations: There have been no recent reports of mental hospitalizations.

Medication Trials: A. G. GERD symptoms are managed with omeprazole, and her sleep problems with trazodone.

Psychotherapy or Previous Psychiatric Diagnosis: A. G. is now attending weekly therapy sessions to address his depression and alcohol consumption. No previous psychiatric diagnoses or psychotherapy history.

Substance Current Use and History:

The urge to stop drinking has been prompted by A. G.’s present everyday habit of drinking. There is a need to change, and he acknowledges it is hurting family life. There is a history of alcohol misuse, which has been worsened by a familial history of verbal abuse from the father and alcoholism. A. G. stopped smoking eighteen years ago. It is evident that the patient is dedicated to their recovery as they are actively seeking treatment help to address their alcohol problem. In order to strengthen resistance against relapse, the present strategy involves recording treatment sessions. This will be especially helpful when faced with temptations to visit the liquor shop. Comprehensive Psychiatric Evaluation Note And Patient Case Presentation Paper

Family Psychiatric/Substance Use History: 

There is a strong pattern of drug abuse and mental health difficulties in A. G.’s family history. His dad has a history of verbal as well as alcohol abuse; he’s 62 years old. A. G.’s mom has a history of drinking too much, too. Because of this family dynamic, A. G. probably has it worse when it comes to his alcoholism and mental health.

Psychosocial History: 

His childhood was characterized by verbal abuse and drunkenness from his father. He is the father of two girls, ages 15 and 17. A. G. lives at home with his family and is aware that his drinking affects their relationship. He managed to kick the habit of smoking 18 years ago, but now he has to deal with the effects of his daily alcohol drinking on his family. A. G.’s dedication to self-improvement is evident in his treatment for depression and alcoholism.

Medical History:

Current Medications: A. G. is now taking trazodone for sleep problems and omeprazole, a daily pill, for the treatment of GERD.

Allergies: He is not allergic to any food or drugs.

Reproductive History: A. G. notes a reduction in sexual activity with his wife.

System Review (ROS): 

General: A. G. states that her everyday alcohol usage is the source of his ongoing discomfort and weariness. The patient did not experience any significant changes in weight, fever, or night sweats.

HEENT (Head, Eyes, Nose, Throat): No problems with their hearing or eyesight, headaches, throat discomfort, or stuffy nose.

The skin: No change in shape or form. Comprehensive Psychiatric Evaluation Note And Patient Case Presentation Paper

Cardiovascular: No symptoms of chest pain, palpitations, or edema have been reported.

Respiratory system: No reports of trouble breathing, coughing, or wheezing.

Gastrointestinal. No gastrointestinal side effects such as nausea, vomiting, or altered bowel habits have been reported.

Genitourinary: No complaints of urgency, hematuria, or urgency were mentioned.

The neurological. There is no indication of any cognitive disorders, convulsions, or localized neurological deficits.

Musculoskeletal system.: no issue noted.

Hematologic: There is no indication of abnormal bleeding, severe bruising, or blood issues based on the patient’s history.

Lymphatic system: There is no indication of enlargement or discomfort in the lymph nodes.

Endocrine: There have been no reports of changes in weight, appetite, and excessive thirst.

Objective:

A.G.,45, had cooperative behavior, calm attitude, clear speaking, and euthymic mood throughout the psychiatric evaluation. Both motor and sensory functions were found to be normal.

Diagnostic results:

Alcohol Use Disorder Identification Test (AUDIT): The AUDIT, which is used to measure alcohol use, dependency, and associated problems, probably produced a result that suggests problematic drinking habits (Moehring et al., 2019). The AUDIT result is consistent with a clinical diagnosis of alcohol use disorder, considering A. G.’s daily alcohol use and the stated effect on his family life. This information is crucial for creating a personalized treatment plan for A. G. that takes into account his mental health and family dynamics, in addition to measures to control and overcome his alcohol dependency. Comprehensive Psychiatric Evaluation Note And Patient Case Presentation Paper

Generalized Anxiety Disorder 7 (GAD-7): His anxiety problems were probably measured by a standardized screening technique called the GAD-7. The GAD-7 score is consistent with clinical findings of elevated anxiety levels, considering A. G.’s stated worries about everyday life, familial neglect, and decreased sexual activity (Rutter & Brown, 2017). This data is essential for developing individualized treatments for anxiety symptoms, which may include therapy methods, coping mechanisms, and mindfulness practices. The GAD-7 result highlights the need to investigate and treat A. G.’s underlying anxiety, which is causing her general mental health issues.

Trauma Screening (TSQ): The TSQ, which is meant to detect and evaluate symptoms associated with trauma, probably showed that A. G. had such symptoms. The clinical awareness of the effect of trauma on his mental health is supported by the TSQ result, considering his history of trauma, which includes verbal abuse at the hands of his father and a claimed need for trauma recovery (de Bont et al., 2015). This data is crucial for developing individualized treatment plans to help people recover from trauma by addressing their unique needs and facilitating access to resources. Comprehensive Psychiatric Evaluation Note And Patient Case Presentation Paper

Imaging Studies: The need to rule out any structural or neurological problems, together with A. G.’s stated symptoms, may necessitate imaging investigations, such as a C.T. or MRI scan of the brain. The goal of these investigations is to find any abnormalities, tumors, lesions, or other anomalies that might be causing his mental health issues by providing thorough images. Considering the medical setting and the possible advantages and diasadvantages, a joint choice should be taken to pursue such imaging, even if it is not standard in mental health examinations.

Assessment:

Mental Status Examination:

1. G., a 45-year-old man, seemed calm and composed in casual grooming and a willingness to cooperate. The absence of any abnormal motor activity suggests that the motor functions normally. His speech is modulated tone correctly, and spoke clearly. His thought process exhibits no symptoms of flight of ideas,  and his mental process seems goal-directed and rational. His affect reflected the euthymic mood. On perception, A. G. demonstrated normal vision and hearing by denying experiencing any hallucinations. On a cognitive level, he was alert and oriented and showed no signs of memory loss. A, G. admitted to having trouble sleeping and uses trazodone to control it. On insight, no suicidal or homicidal thoughts were recorded at this time, suggesting that his mental health is stable.

Differential Diagnosis

Major Depressive Disorder (F32): The symptoms that A. G. has described, which include a poor mood, lack of interest in things, ignoring family, and diminished sexual activity, are consistent with Major Depressive Disorder (MDD) (Otter et al., 2016). An initial diagnosis of major depressive disorder should be considered because of his past experiences of depression and its effects on his ability to carry out everyday tasks.

Generalized Anxiety Disorder (F41.1): Worry over day-to-day living and family relationships are among the major anxiety symptoms that suggest the potential of GAD (DeMartini et al., 2019). There needs to be focused therapies to address the symptoms of anxiety, and the GAD-7 finding adds credence to this idea (Foo Kune & Unsworth, 2018). Comprehensive Psychiatric Evaluation Note And Patient Case Presentation Paper

Alcohol Use Disorder (F10.10): The fact that A. G. drinks alcohol every day, admits to ignoring his family, and knows it affects his sexual performance all point to the possibility that he has alcohol use disorder (Carvalho et al., 2019). This diagnosis is likely aided by the AUDIT result, which highlights the need for focused measures to tackle problematic alcohol consumption.

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Major Depressive Disorder (F32) is the primary diagnosis.

The significant presence of depressed symptoms, such as low mood, limited interest, as well as impaired daily functioning, makes the main diagnosis of Major depressed Disorder (MDD) the most important. The DSM-5-TR diagnosis criteria for MDD are supported by A. G.’s stated history of depression and its influence on family life. More than two weeks have passed with the existence of five symptoms, including a sad mood and impaired interest or pleasure (Barajas & Davis III, 2018). The thorough evaluation corroborated the diagnosis, recognizing the far-reaching effects of A. G.’s depression. A minimum of five depressive symptoms must be present during a two-week period in order for MDD to be classified according to the DSM-5-TR criteria. Depression is characterized by a lack of interest in or enjoyment from previously enjoyed activities, changes in eating habits or weight, trouble sleeping, restlessness or slowness in psychomotor skills, extreme exhaustion, feelings of shame or worthlessness, trouble focusing, and frequent thoughts of suicide (Otte et al., 2016). Comprehensive Psychiatric Evaluation Note And Patient Case Presentation Paper

Case Formulation and Treatment Plan:

1. G. will be receiving Cognitive-Behavioral Therapy (CBT) with an emphasis on trauma-focused techniques as part of his psychotherapy program. When it comes to treating symptoms of depression, anxiety, and unhealthy ways of coping, cognitive behavioral therapy (CBT) has a solid track record of success. Trauma healing, coping skill development, and re-framing negative alcohol-related cognitive patterns are the main objectives. Cognitive behavioral therapy (CBT) aims to help people recognize and change unhelpful ways of thinking, as well as to encourage cognitive restructuring and the development of adaptive coping mechanisms (Hollon & Beck, 2013). A more resilient person may emerge from adversity with the help of trauma-focused components that facilitate the processing and investigation of traumatic events.

An important part of this is teaching people how to cope with mental health issues, including anxiety, depression, and alcoholism. So that he may make an educated choice, A. G. will find out how his alcoholism relates to his mental health issues. Also, stress management, anxiety reduction, and improved emotional control may all result from a program that combines mindfulness with training in coping skills. A. G. will build plans to deal with situations that make him want to drink. Also, the patient’s medical history will be carefully considered while implementing exposure treatment in order to help with the desensitization of emotional reactions to traumatic memories and the subsequent promotion of trauma healing. The plan for follow-up sessions is to meet once a week at the beginning and then twice a week as the program progresses. Symptom improvements, treatment adherence, and course corrections may be tracked with regular evaluations. Therapy will continue under A. G.’s supervision is determined by collaborative talks. Comprehensive Psychiatric Evaluation Note And Patient Case Presentation Paper

For referrals, considering the extent of depressive symptoms as well as alcohol dependency, it is advisable to consult with a psychiatrist to evaluate the possible need for medication treatment. Incorporating support groups is also important. Connecting A. G. with alcohol use disorder support groups can help her find more resources while also building her feeling of community and empathy. Not to mention family therapy, A. G.’s family dynamics, and healing may both benefit from family members’ participation in therapy sessions when it is suitable. Lastly, a referral to an experienced gastroenterologist for a thorough medical assessment is recommended in case of high liver enzymes. This will help evaluate the liver’s condition and provide advice on possible lifestyle changes.

Reflection

If I were assessing a patient with identical symptoms, I would get family members involved. It may be helpful to get insight into possible triggers and support networks by learning about the family dynamics, particularly in situations where there is a past of drug addiction and mental health difficulties. A more all-encompassing strategy for recovery and a more complete support system for the patient might be achieved by including family members in treatment sessions. Comprehensive Psychiatric Evaluation Note And Patient Case Presentation Paper

Taking into account the socioeconomic determinants of health, the client’s family dynamics, as well as past experiences with childhood trauma, underscore the influence of these variables on mental health. One important approach might be to look into programs and services that can help families overcome the cycle of drug misuse and mental health difficulties. Improving mental health in the long run may be possible with efforts to stabilize the economy, provide access to good education, and strengthen communities (Silva et al., 2016).

One potential health promotion strategy for a future advanced practice healthcare provider may be to launch community outreach initiatives to raise awareness about mental health issues, combat stigma, and give tools for early intervention. In order to normalize getting treatment and promote proactive mental wellness management, patient education should stress the need for frequent mental health check-ups, analogous to regular physical check-ups. By eliminating obstacles to care and elevating mental well-being as a component of total wellness, this strategy hopes to close the gap in health outcomes.

References

Barajas, M. S., & Davis III, C. (2018). F32 Major depressive disorder, single episode. https://psycnet.apa.org/doi/10.1037/0000069-006

Carvalho, A. F., Heilig, M., Perez, A., Probst, C., & Rehm, J. (2019). Alcohol use disorders. The Lancet, 394(10200), 781-792. https://doi.org/10.1016/S0140-6736(19)31775-1

de Bont, P. A., van den Berg, D. P., van der Vleugel, B. M., de Roos, C., de Jongh, A., van der Gaag, M., & van Minnen, A. (2015). Predictive validity of the Trauma Screening Questionnaire in detecting post-traumatic stress disorder in patients with psychotic disorders. The British Journal of Psychiatry, 206(5), 408-416. https://doi.org/10.1192/bjp.bp.114.148486

DeMartini, J., Patel, G., & Fancher, T. L. (2019). Generalized anxiety disorder. Annals of internal medicine, 170(7), ITC49-ITC64.

Foo Kune, N. M., & Unsworth, S. (2018). F41. 1 Generalized anxiety disorder. https://psycnet.apa.org/doi/10.1037/0000069-009

Hollon, S. D., & Beck, A. T. (2013). Cognitive and cognitive-behavioral therapies. Bergin and Garfield’s handbook of psychotherapy and behavior change, 6, 393-442.

Moehring, A., Rumpf, H. J., Hapke, U., Bischof, G., John, U., & Meyer, C. (2019). Diagnostic performance of the alcohol use disorders identification test (AUDIT) in detecting DSM-5 alcohol use disorders in the general population. Drug and alcohol dependence, 204, 107530. https://doi.org/10.1016/j.drugalcdep.2019.06.032

Otte, C., Gold, S. M., Penninx, B. W., Pariante, C. M., Etkin, A., Fava, M., … & Schatzberg, A. F. (2016). Major depressive disorder. Nature reviews Disease primers, 2(1), 1-20.

Rutter, L. A., & Brown, T. A. (2017). Psychometric properties of the generalized anxiety disorder scale-7 (GAD-7) in outpatients with anxiety and mood disorders. Journal of psychopathology and behavioral assessment, 39, 140-146. https://doi.org/10.1007/s10862-016-9571-9

Silva, M., Loureiro, A., & Cardoso, G. (2016). Social determinants of mental health: a review of the evidence. The European Journal of Psychiatry, 30(4), 259-292. Comprehensive Psychiatric Evaluation Note And Patient Case Presentation Paper

Grading Criteria

 

 

1-Discuss Subjective data:• Chief complaint• History of present illness (HPI)• Medications• Psychotherapy or previous psychiatric diagnosis• Pertinent histories and/or ROS

 

2-Discuss Objective data:• Physical exam documentation of systems pertinent to the chief complaint, HPI, and history• Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses’

3- Discuss results of Assessment:• Results of the mental status examination• 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 diagnostic criteria and is supported by the patient’s symptoms. Comprehensive Psychiatric Evaluation Note And Patient Case Presentation Paper

4- Discuss treatment Plan:• A treatment plan for the patient that addresses psychotherapy and rationales including a plan for follow-up parameters and referral

INSTRUCTIONS ON HOW TO USE EXEMPLAR AND TEMPLATE—READ CAREFULLY

If you are struggling with the format or remembering what to include, follow the Comprehensive Psychiatric Evaluation Template AND the Rubric as your guide.  It is also helpful to review the rubric in detail in order not to lose points unnecessarily because you missed something required. Below highlights by category are taken directly from the grading rubric for the assignments. After reviewing full details of the rubric, you can use it as a guide.

In the Subjective section, provide:

• Chief complaint
• History of present illness (HPI)
• Past psychiatric history
• Medication trials and current medications
• Psychotherapy or previous psychiatric diagnosis
• Pertinent substance use, family psychiatric/substance use, social, and medical history
• Allergies
• ROS
• Read rating descriptions to see the grading standards! Comprehensive Psychiatric Evaluation Note And Patient Case Presentation Paper
  

In the Objective section, provide:

• Physical exam documentation of systems pertinent to the chief complaint, HPI, and history
• Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses.
• Read rating descriptions to see the grading standards!
  

In the Assessment section, provide:

• Results of the mental status examination, presented in paragraph form.
• At least three differentials with supporting evidence. List them from top priority to least priority. Compare the DSM-5 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.
• Read rating descriptions to see the grading standards! Comprehensive Psychiatric Evaluation Note And Patient Case Presentation Paper

Reflect on this case. Include what you learned and what you might do differently. 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.).

(The comprehensive evaluation is typically the initial new patient evaluation. You will practice writing this type of note in this course. You will be ruling out other mental illnesses so often you will write up what symptoms are present and what symptoms are not present from illnesses to demonstrate you have indeed assessed for all illnesses which could be impacting your patient. For example, anxiety symptoms, depressive symptoms, bipolar symptoms, psychosis symptoms, substance use, etc.)

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EXEMPLAR BEGINS HERE

CC (chief complaint): A brief statement identifying why the patient is here. This statement is verbatim of the patient’s own words about why they are presenting for assessment. For a patient with dementia or other cognitive deficits, this statement can be obtained from a family member.

HPI: Begin this section with patient’s initials, age, race, gender, purpose of evaluation, current medication, and referral reason. For example:

N.M. is a 34-year-old Asian male who presents for psychotherapeutic evaluation for anxiety. He is currently prescribed sertraline by (?) which he finds ineffective. His PCP referred him for evaluation and treatment.

Or

P.H. is a 16-year-old Hispanic female who presents for psychotherapeutic evaluation for concentration difficulty. She is not currently prescribed psychotropic medications. She is referred by her mental health provider for evaluation and treatment. Comprehensive Psychiatric Evaluation Note And Patient Case Presentation Paper

Then, this section continues with the symptom analysis for your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis.

Paint a picture of what is wrong with the patient. This section contains the symptoms that is bringing the patient into your office. The symptoms onset, the duration, the frequency, the severity, and the impact. Your description here will guide your differential diagnoses. You are seeking symptoms that may align with many DSM-5 diagnoses, narrowing to what aligns with diagnostic criteria for mental health and substance use disorders. You will complete a psychiatric ROS to rule out other psychiatric illnesses.

Past Psychiatric History: This section documents the patient’s past treatments. Use the mnemonic Go Cha MP. 

General Statement: Typically, this is a statement of the patients first treatment experience. For example: The patient entered treatment at the age of 10 with counseling for depression during her parents’ divorce. OR The patient entered treatment for detox at age 26 after abusing alcohol since age 13.

Caregivers are listed if applicable.

Hospitalizations: How many hospitalizations? When and where was last hospitalization? How many detox? How many residential treatments? When and where was last detox/residential treatment? Any history of suicidal or homicidal behaviors? Any history of self-harm behaviors? Comprehensive Psychiatric Evaluation Note And Patient Case Presentation Paper

Medication trials: What are the previous psychotropic medications the patient has tried and what was their reaction? Effective, Not Effective, Adverse Reaction? Some examples: Haloperidol (dystonic reaction), risperidone (hyperprolactinemia), olanzapine (effective, insurance wouldn’t pay for it)

Psychotherapy or Previous Psychiatric Diagnosis: This section can be completed one of two ways depending on what you want to capture to support the evaluation. First, does the patient know what type? Did they find psychotherapy helpful or not? Why? Second, what are the previous diagnosis for the client noted from previous treatments and other providers. (Or, you could document both.)

Substance Use History: This section contains any history or current use of caffeine, nicotine, illicit substance (including marijuana), and alcohol. Include the daily amount of use and last known use. Include type of use such as inhales, snorts, IV, etc. Include any histories of withdrawal complications from tremors, Delirium Tremens, or seizures.

Family Psychiatric/Substance Use History: This section contains any family history of psychiatric illness, substance use illnesses, and family suicides. You may choose to use a genogram to depict this information (be sure to include a reader’s key to your genogram) or write up in narrative form.

Psychosocial History: This section may be lengthy if completing an evaluation for psychotherapy or shorter if completing an evaluation for psychopharmacology.  However, at a minimum, please include:

• Where patient was born, who raised the patient
• Number of brothers/sisters (what order is the patient within siblings)
• Who the patient currently lives with in a home? Are they single, married, divorced, widowed? How many children? Comprehensive Psychiatric Evaluation Note And Patient Case Presentation Paper
• Educational Level
• Hobbies
• Work History: currently working/profession, disabled, unemployed, retired?
• Legal history: past hx, any current issues?
• Trauma history: Any childhood or adult history of trauma?
• Violence Hx: Concern or issues about safety (personal, home, community, sexual (current & historical)

 

Medical History: This section contains any illnesses, surgeries, include any hx of seizures, head injuries.

 

Current Medications: Include dosage, frequency, length of time used, and reason for use. Also include OTC or homeopathic products.

Allergies: Include medication, food, and environmental allergies separately. Provide a description of what the allergy is (e.g., angioedema, anaphylaxis). This will help determine a true reaction vs. intolerance.

Reproductive Hx: Menstrual history (date of LMP), Pregnant (yes or no), Nursing/lactating (yes or no), contraceptive use (method used), types of intercourse:  oral, anal, vaginal, other, any sexual concerns

Diagnostic results: Include any labs, X-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines).

Assessment

Mental Status Examination: For the purposes of your courses, this section must be presented in paragraph form and not use of a checklist! This section you will describe the patient’s appearance, attitude, behavior, mood and affect, speech, thought processes, thought content, perceptions (hallucinations, pseudo hallucinations, illusions, etc.), cognition, insight, judgment, and SI/HI. See an example below. You will modify to include the specifics for your patient on the above elements—DO NOT just copy the example. You may use a preceptor’s way of organizing the information if the MSE is in paragraph form.  Comprehensive Psychiatric Evaluation Note And Patient Case Presentation Paper

He is an 8 yo African American male who looks his stated age. He is cooperative with examiner. He is neatly groomed and clean, dressed appropriately. There is no evidence of any abnormal motor activity. His speech is clear, coherent, normal in volume and tone. His thought process is goal directed and logical. There is no evidence of looseness of association or flight of ideas. His mood is euthymic, and his affect appropriate to his mood. He was smiling at times in an appropriate manner. He denies any auditory or visual hallucinations. There is no evidence of any delusional thinking.   He denies any current suicidal or homicidal ideation. Cognitively, he is alert and oriented. His recent and remote memory is intact. His concentration is good. His insight is good.

Differential Diagnoses: You must have at least three differentials with supporting evidence. Explain what rules each differential in or out and justify your primary diagnosis selection. Include pertinent positives and pertinent negatives for the specific patient case.

 

 

Also included in this section is the reflection. Reflect on this case and discuss whether or not you agree with your preceptor’s assessment and diagnostic impression of the patient and why or why not. What did you learn from this case? What would you do differently?

Also include in your reflection a discussion related to legal/ethical considerations (demonstrating critical thinking beyond confidentiality and consent for treatment!), social determinates of health, 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.). Comprehensive Psychiatric Evaluation Note And Patient Case Presentation Paper

 

Case Formulation and Treatment Plan.

Includes documentation of diagnostic studies that will be obtained, referrals to other health care providers, therapeutic interventions with psychotherapy, education, disposition of the patient, and any planned follow-up visits. Each diagnosis or condition documented in the assessment should be addressed in the plan. The details of the plan should follow an orderly manner.  *see an example below—you will modify to your practice so there may be information excluded/included—what does your preceptor document?

Example:

Initiation of (what form/type) of individual, group, or family psychotherapy and frequency.

Documentation of any resources you provide for patient education or coping/relaxation skills, homework for next appointment. Comprehensive Psychiatric Evaluation Note And Patient Case Presentation Paper

Client has emergency numbers:  Emergency Services 911, the  Client’s Crisis Line 1-800-_______. Client instructed to go to nearest ER or call 911 if they become actively suicidal and/or homicidal. (only if you or preceptor provided them)

 

Reviewed hospital records/therapist records for collaborative information; Reviewed PCP report (only if actually available)

 

Time allowed for questions and answers provided. Provided supportive listening. Client appeared to understand discussion. Client is amenable with this plan and agrees to follow treatment regimen as discussed. (This relates to informed consent; you will need to assess their understanding and agreement.)

 

Follow up with PCP as needed and/or for:

 

Write out what psychotherapy testing or screening ordered/conducted, rationale for ordering

 

Any other community or provider referrals

 

Return to clinic:

 

Continued treatment is medically necessary to address chronic symptoms, improve functioning, and prevent the need for a higher level of care OR if one-time evaluation, say so and any other follow up plans. Comprehensive Psychiatric Evaluation Note And Patient Case Presentation Paper

References (move to begin on next page)

You are required to include at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines which relate to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting.

Case Study

A. G. is a 45-year-old male with a history of alcohol abuse, anxiety, PTSD, and depression. The patient has been drinking liquor every day and is trying to stop it. The patient has two daughters, 15 and 17 years old. The patient explained that the drinking habit is affecting her family; he feels that he is not present in the house, he is neglecting her family, and he is not sexually active with his wife. The patient quit smoking 18 years ago and felt like he could stop the alcohol one day. The patient explained that he came from a family where his father was verbally abusive. His father is 62 years old and has a history of alcohol abuse, and his mother as well. The patient has a sleep issue for which he is taking trazodone. The patient has a history of Gastroesophageal reflux disease ( GERD), for which he is taking omeprazole 20 mg every day. The patient attends his therapy session every week to help him with depression and alcohol abuse.
During his mental status examination, the patient is cooperative with the therapist. He is casually groomed and cleanly dressed appropriately. There is no evidence of any abnormal motor activity. His speech is clear, coherent, and normal in volume and tone. His thought process is goal-directed and logical. There is no evidence of looseness of association or flight of ideas. His mood is euthymic, and his effect is appropriate to his mood. He denies any auditory or visual hallucinations. There is no evidence of any delusional thinking. He denies any current suicidal or homicidal ideation. Cognitively, he is alert and oriented. His recent and remote memory is intact. His concentration is fair. His insight is good. Comprehensive Psychiatric Evaluation Note And Patient Case Presentation Paper
Therapy session plan
The patient wants to work in the next session on trauma recovery, learning coping skills, meditation, being able to stay still, and controlling negative thoughts. The patient will record her sessions and watch them over each time he plans to go to the liquor store. The patient will work on having positive thoughts, saying to himself that he deserves a good life, and not letting the negative thoughts go to the liquor store.

Deferential diagnostic
1-Mejor depressive disorder (F32)
2-Generalized anxiety disorder ( F41.1)
3-Alcohol use disorder (F10.10)

• 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.
o 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? Comprehensive Psychiatric Evaluation Note And Patient Case Presentation Paper
o Objective: What observations did you make during the psychiatric assessment?
o Assessment: Discuss the patientâ€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 patientâ€s symptoms.
o 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?
o 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? Comprehensive Psychiatric Evaluation Note And Patient Case Presentation Paper