Comprehensive Psychiatrist Evaluation Note paper

Chief Complaint: excessive fear of contamination and frequent hand washing for over one month

History Of The Presenting Illness:

Q.A is a 26years old American female who attended the psychiatric clinic with complaints of excessive fear of contamination and frequent hand washing. The onset of these symptoms was one month ago and increased gradually to the extent of disturbing her daily work routine. Her spouse reports that she has been experiencing panic attacks at the scene of dirt. This makes her clean the entire house and thoroughly clean her hands because she believes she can get an infection due to the dirty surface. She reports having persistent thoughts about how her mother passed on in a dirty environment. The scene scares her such that she cleans around the house to give her a calming effect. Apart from the obsessive behavior, she has been experiencing anxiety, mood swings,  excessive feeding, and depressive mood. However, she does not have suicidal ideation or unwanted intrusive sexual thoughts. Comprehensive Psychiatrist Evaluation Note paper

Past Psychiatric History

The patient was previously treated for depressive mood disorder two years ago after the demise of her mother and son. She lives with her spouse, who had been her caregiver, and followed through with her treatment course. She was previously hospitalized two years ago due to major depressive mood disorder and a suicidal attempt. She was discharged on fluoxetine and later stopped after recovery from the depressive mood.

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Medication Trial

The patient was using fluoxetine 20mg orally once daily for one year that relieved the depressive mood. Currently, the patient is not on any medication

Psychotherapy or previous psychiatric diagnosis:

During the previous diagnosis of major depressive mood disorder, the patient attended 60 minutes sessions of cognitive-behavioral therapy every week for six months. The CBT sessions were effective in reducing the depression symptoms. Comprehensive Psychiatrist Evaluation Note paper

Substance use history: The patient denies the use of alcohol and other substances.

Family Psychiatric/ Substance Use History:

The patient is the third born in her family. Her father committed suicide at the age of 45years due to substance-induced psychosis. Her father abused cocaine, smoked marijuana, and had alcohol intake in his lifetime. Her mother and siblings have no positive history of substance abuse.

Psychosocial History

The patient was born and raised in New York in the United States of America. She was raised up by her father and mother as the third born child in a family of five. She is married and has three children. She stays with her husband and the three children. She has studied up to the university level doing her master's in finance. She has worked as an operations manager for three years. She stopped after the diagnosis of major depressive mood disorder. She took a compassionate leave because she had difficulties concentrating.  She enjoys swimming, singing in the church choir, and reading novels. She has no history of legal issues, childhood or adult traumas, and sexual and physical violence.

Medical history: The patient is known to have asthma. She has not undergone a minor or major surgical procedure.

Current medication: She takes a salbutamol inhaler when she gets an attack

Allergies: she is allergic to cold, dust, fur, and pollen. She has no known history of drug and food allergies.

Reproductive history: the patient’s last menstrual period was on 20/9/2021, she is not lactating, uses combined oral contraceptives, and engages in vaginal sexual intercourse.

Diagnostic results:

The diagnostic investigations are magnetic resonance imaging and positron emission tomography scanning which shows increased blood supply to the orbitofrontal cortex.

Assessment

Mental Status Examination

The patient is well-kempt, presentable, and looks as stated by age. She is restless and has cracked hands and keeps on sanitizing. Her speech is of soft tone, decreased rate, and volume with vocal tremor. She seems worried and anxious with a sad mood. She has negative thoughts about herself and experiences undesired recurrent thoughts with repetitive behavior of cleaning her hands. She believes in cleanliness and everyone should observe that. She has difficulties focusing on her main goal. However, he has no suicidal ideations, delusions, and hallucinations.

Differential Diagnosis

Obsessive-compulsive disorder

Major depressive mood disorder

Generalized anxiety disorder

Obsessive-compulsive disorder is a distressing, intrusive obsessive thought or repetitive compulsive physical act. Common obsessions are about safety, doubting of one's memory or perception, unwanted intrusive aggressive thoughts, and the need to do the right thing (Robbins, et al, 2019). The compulsive behavior includes hand washing, arranging objects, seeking assurance, and repeating actions until it feels right. The American psychiatric association classifies obsessive-compulsive disorder with, recurrent thoughts that cause marked anxiety, repetitive behavior such as hand washing, behavior or act that aims at reducing stress and the dreaded situation. Comprehensive Psychiatrist Evaluation Note paper

Major depressive mood disorder is mental health illness associated with disruption of interpersonal skills, substance abuse, and lost work (Hasin, et al, 2018). The presenting symptoms are physical retardation, loss of emotional expression, and psychomotor agitation or restlessness. Other presenting symptoms are poor feeding habits, suicidal ideation, generalized fatigue, sleep disturbance, and loss of concentration.

Generalized anxiety disorder is excessive fear or anxiety related to behavioral disturbances. The causes of generalized anxiety disorders can be genetic, environmental, and past traumatic experiences (Cui, et al, 2018). The presenting signs and symptoms are restlessness, fatigue, irritability, loss of concentration, sleep disturbances, and muscle tension. This is not the actual diagnosis because the patient presents with obsessive and compulsive behavior.

Obsessive-compulsive disorder is the primary diagnosis for this patient because the patient presenting complaint is an excessive fear of contamination and frequent hand washing. In the mental assessment, the patient has obsessive compulsive behavior because she has cracked hands due to frequent hand washing, she keeps on sanitizing, she explains her recurrent thoughts of failure to sanitize. She believes handwashing prevents infections and death. Despite having poor concentration, altered feeding habits, and depressive mood, the patient does not have a major depressive mood disorder because she has no sign of agitation, sleep disturbances, and suicidal ideation.

Reflection Note

Obsessive-compulsive disorder is a chronic illness associated with significant impairment in functioning. Its diagnosis is often missed due to the patient's fear of stigma. The obsession personality is usually related to compulsive behavior (Robbins, et al, 2019). The patient has the fear of contamination due to its undesirable effects. Therefore, he keeps on sanitizing and washing his hands. Causes of Obsessive-compulsive disorder are genetic influence, infectious disease, stress, and neurological conditions. Obsessive-compulsive disorder has a potential of severity though there is a significant improvement to those who seek treatment. Patient education about the disease process erases the family's misconception about the illness and supports the patient in the healthcare process. The challenging bit when handling this patent was her vocal tremor that made communication difficult. She also had anger outbursts and restlessness that made it difficult to interview. I learned that Obsessive-compulsive disorders are real and worsen if not treated. They disrupt the interpersonal relationships and the cognitive functions of patients. In the next interview, I will be patient when listening and ask more open-ended questions. Comprehensive Psychiatrist Evaluation Note paper

Ethical Considerations

Obsessive-compulsive disorder just like any other psychiatric illness is associated with stigma. When treating these patients, a psychiatric nurse should ensure there is privacy and confidentiality during treatment. The patient consents on who should be disclosed to about her diagnosis. Another ethical considerations are non-maleficence where the care provider ensures patient safety during treatment. The patient deserves the best medical attention without discrimination. The care provider should respect the patient's decisions during treatment.

Health promotion

Public awareness of Obsessive-compulsive disorder helps them to learn about the signs and symptoms. This enables the community to appreciate and respect patients with mental health issues (Cavioni, et al, 2020). Being aware of the signs and symptoms prevents the occurrence of impending mental health illnesses. Providing specialized healthcare providers helps in treating the available cases in the community.

Case Formulation And Treatment Plan

Pharmacological: Fluoxetine 40mg P.O OD for one month

Non-pharmacological

Humanistic existential psychotherapy is the treatment of choice for this patient because of the obsessive compulsive disorder. Existential psychotherapy focuses on the human condition as a whole by discussing the profound issues during the counseling. It enables the patient discover their uniqueness and the world around them. It will be useful in this patient by creating awareness to the patient about their unique obsessive and compulsive personality disorder. The patient is expected to develop a personal identity for quality relationships, improve their communication skills, take responsibility of their own decisions, become authentic, accept normal anxiety, and recognize death and non-existence. Other psychotherapy methods reduce anxiety and obsession compulsive behavior but do not create self-awareness.

Patient education

Follow-up with the psychiatrist for improvement assessment

The patient is allowed to visit the hospital in case of any emergency or consult the PCP over the phone call.

USE THIS TEMPLATE AS AN EXAMPLE

The ASSIGNMNET:. THE IMPULSE DISORDER TO USE IS OCD

Select a group patient for whom you conducted psychotherapy for an impulse control or conduct disorder during the last 6 weeks. Create a Comprehensive Psychiatric Evaluation Note on this patient using the template provided in the Learning Resources.  USE THE COMPLETED TEMPLATE BELOW AS A GUIDE AND EXAMPLE. PLEASE, DO NOT MISS ANY PART OF THE TEMPLATE , INCLUDE ALL SESSION AS SHOWN IN THE TEMPLATE  BELOW. There is also a completed template provided as an exemplar and guide

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. Comprehensive Psychiatrist Evaluation Note paper

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!

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!

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.)

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.

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?

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?
• 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) Comprehensive Psychiatrist Evaluation Note paper

 

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.

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.  Comprehensive Psychiatrist Evaluation Note paper

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 treatment 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 (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.).

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? Comprehensive Psychiatrist Evaluation Note paper

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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.

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.

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. Comprehensive Psychiatrist Evaluation Note paper

References

Cavioni, V., Grazzani, I., & Ornaghi, V. (2020). Mental health promotion in schools: A comprehensive theoretical framework.

Cui, Q., Sheng, W., Chen, Y., Pang, Y., Lu, F., Tang, Q., ... & Chen, H. (2020). Dynamic changes of amplitude of low‐frequency fluctuations in patients with generalized anxiety disorder. Human brain mapping, 41(6), 1667-1676.

Hasin, D. S., Sarvet, A. L., Meyers, J. L., Saha, T. D., Ruan, W. J., Stohl, M., & Grant, B. F. (2018). Epidemiology of adult DSM-5 major depressive disorder and its specifiers in the United States. JAMA psychiatry, 75(4), 336-346.

Robbins, T. W., Vaghi, M. M., & Banca, P. (2019). Obsessive-compulsive disorder: puzzles and prospects. Neuron, 102(1), 27-47. Comprehensive Psychiatrist Evaluation Note paper