Comprehensive Psychiatric Evaluation Note and Patient Case Presentation, Part 1

Subjective:

CC (chief complaint):

CR, a 67-year-old female patient, has developed frustration and anxiety caused by chronic pain and COVID-19, which has been confirmed to have resolved. She notes that she gets bogged down because she is unable to do things that used to give her pleasure, and she worries about her inability to control physical pain. She says her mood is low, and she often ponders over her health condition and what she cannot do: Comprehensive Psychiatric Evaluation Note and Patient Case Presentation, Part 1.

HPI:

CR suffers from chronic pain and sometimes knock-out mood symptoms that must have affected her quality of life. In the past few months, she reported frustration, anxiety, and depressive symptoms that have deteriorated since developing COVID-19. While she had a COVID-19 infection, she has recovered from it, but she is still tired and angry at herself due to chronic pain. Panic disorder and bipolar II disorder have been a part of her history for a while now, and mood swings are likely coming from these.

CR has noted an increase in the symptoms of anxiety in the last one and a half to two weeks, mainly when thinking about chronic pain and the restrictions that it involves. She is not efficient in regulating her emotions about pain and other forms of physical discomfort; she develops anxiety and depression. These symptoms persist and negatively affect her social activities and leisure passions like reading and walking.

Past Psychiatric History:

• General Statement: CR, a 67-year-old female, reported bipolar II disorder, depressive and hypomanic episodes, and panic disorder. In recent weeks, she has had signs of aggravation with pain and post-COVID fatigue.
• Caregivers (if applicable): CR’s daughter provides primary caregiving support, including emotional and practical assistance. Neighbors help with errands.
• Hospitalizations: No recent psychiatric hospitalizations. Past medical hospitalizations for hypertension and emergency care for panic attacks.
• Medication trials:
  • Clonazepam (PRN) for anxiety.
  • Lisinopril for hypertension.
  • Previous anti-depressants (such as sertraline), lamotrigine, for bipolar II disorder: stopped due to side effects and non-compliance
• Psychotherapy or Previous Psychiatric Diagnosis: Sporadic CBT for anxiety and depression symptoms. Diagnoses have included bipolar II disorder, panic disorder, and primary hypertension.

Substance Current Use and History:

• Tobacco: She affirms she is a non-smoker.
• Alcohol: Infrequent, 1-2 drinks per week.
• Recreational Drugs: Refutes use.

Family Psychiatric/Substance Use History:

• Mother: Died at age 75 with a history of depression.
• Father: Deceased at age 80, history of hypertension.
• Siblings: One brother, age 70, with a history of anxiety and depression.
• Substance Use: No significant history of substance use in the family.

Psychosocial History: The patient lives alone in her home. She has a supportive daughter who assists her with emotional and practical needs, and her neighbors help with errands. Due to chronic pain and anxiety, CR has become less socially active but enjoys reading and light walking when possible.

She is retired and no longer works due to age and health issues. CR has a high school education and does not report any learning difficulties. CR’s support system plays an important role in her daily life.

Medical History:

• Current Medications:
  • Lisinopril for hypertension
  • Clonazepam (PRN) for panic attacks
  • Ibuprofen for chronic pain management
• Allergies: No known drug allergies (NKDA)

• Reproductive Hx: CR is postmenopausal and has no significant reproductive health issues. She has no history of pregnancies or gynecological surgeries.

Objective:

Physical Exam: CR appears well-groomed and in no acute distress but is slightly fatigued. She is alert and oriented to person, place, time, and situation. She is cooperative throughout the exam.

Diagnostic results: No lab or imaging results were provided. Based on the history, CR likely had imaging related to her chronic pain (e.g., X-ray of lumbar spine) in the past to evaluate osteoarthritis, though results were not specified here.

Assessment:

Mental Status Examination: The patient appears well-groomed and is in no acute distress. She is cooperative, maintains eye contact, and demonstrates appropriate behavior during the session. She is alert and oriented to person, place, time, and situation. Her mood is described as “down” and frustrated due to her chronic pain and recent COVID-19 illness.

Her affect is congruent with her mood, though slightly restricted, possibly due to fatigue. Her speech is clear, coherent, and normal in rate and tone, with no signs of pressured speech or speech abnormalities. CR’s thought process is logical, coherent, and goal-directed, with no evidence of thought disorder, delusions, or hallucinations. Her thought content is primarily focused on health concerns, particularly her chronic pain and the limitations it imposes, as well as anxiety related to these issues.

The patient demonstrates fair insight into her condition, recognizing that her pain is affecting her mood and functioning, but she reports difficulty implementing coping strategies independently. Her judgment appears fair as well. She does not display any cognitive impairments, and her memory is intact for both short-term and long-term recall. There is no indication of any perceptual abnormalities, in addition to which CR’s general cognitive standing has been characterized as usual.

Differential Diagnoses:

1. Bipolar II Disorder (Primary Diagnosis)

The primary diagnosis is bipolar II disorder because it addresses all mood aspects in this patient: depressive and hypomanic. CR is in remission for bipolar II disorder and has viral hypomania–depressive symptoms consistent with DSM-5-TR criteria (Vieta, 2019). Concretely, low energy, frustration, and no interest in activities are characteristic of a present depressive episode, according to the DSM-V for CR.

Details of her prior cycling of hypomania, albeit of hypomanic temperament, also favor bipolar II instead of a major depressing disorder (MDD) diagnosis. The pain, as much as it has worsened her symptoms, does not cause mood swings but can cause depression.

1. Panic Disorder
   Panic disorder is considered ruled out, as CR has mentioned episodic paroxysmal anxiety (Cackovic et al., 2020). Previous symptoms include anxiety attacks with breathing difficulties and chest pains. Nevertheless, she seems to have a higher level of current anxiety around chronic pain/health issues, and therefore, bipolar II disorder is a better appropriate primary diagnosis. Moreover, panic attacks occur at some specific time, and they are single, whereas CR’s anxiety is more chronic and is associated with her medical disorders.
2. Generalized Anxiety Disorder (GAD):
   GAD is possible because even after three months, CR still gets worried about their health and the chronic pain she experiences. However, her anxiety is not persistent throughout all areas of her life, and it tends to occur primarily in the context of her physical health concerns (Munir & Takov, 2022). The episodic nature of her mood changes and the fluctuating energy levels observed in her history further suggest that bipolar II disorder is more appropriate, with anxiety as a secondary symptom during depressive episodes.

Reflections:

If I were to conduct a similar patient evaluation, I would place greater emphasis on integrating community and support services into the treatment plan. While CR has a supportive daughter, her limited social engagement due to chronic pain and anxiety highlights the need for more comprehensive community support. In future evaluations, I would take extra care to assess the patient’s social environment more deeply, identifying any barriers to socialization or access to community-based resources that could help mitigate feelings of isolation and improve overall health outcomes. Moreover, I would enhance health literacy interventions by ensuring that CR understands how her mental and physical health co-relate and how enhancing her lifestyle would benefit her in both aspects.

Notably, looking at the social determinants of health (SDOH), economic stability occupies a central position in the current status of CR. Economic stability is recognized as one of the key factors that the Office of Disease Prevention and Health Promotion (2024) has identified to define the population’s health. CR is retired, which may lock her out from booking more tests or seeking more care in cases where she has limited financial means to pay for tests, medications, or therapy regularly. The lack of access to resources could be the reason for her suffering from her health needs, such as pain control and mental health, among other health needs.

Health Promotion Activity

Notably, while dealing with the components of economic stability, another activity that could help promote healthy living to the patient could entail introducing her to local community health programs that charge fees that are on a scale or can organize for financial aid, as highlighted by White et al. (2022). This would thus enable her to attend subsequent physical therapy, pain management, and even mental health checkups within the same clinic without any extra costs. Furthermore, by increasing her engagement in home-based physical activities, the programs might be helpful to decrease her chronic pain and anxiety and improve her quality of life.

Patient Education Consideration

An important area of patient education for CR would be to highlight the importance of dietary changes and exercise in chronic pain and mental health, as Elma et al. (2022) have noted. Teaching her about proper diet (particularly foods with low inflammation factors: omega-3 fatty acids) and appropriate physical activity (strengthening exercises such as stretching or walking) would greatly help her to get rid of the pain and improve her condition, thus helping to decrease symptoms of mental disorder. Also, it would be helpful to teach her about medication management and make her appreciate the necessity of following strict regimes and attending follow-up appointments.

Case Formulation and Treatment Plan:

Modality

The selected treatment approach for CR is cognitive behavioral therapy (CBT). CBT is helpful in mood disorders such as bipolar II disorder and panic disorder because it focuses on the distal feelings and behaviors that cause anxiety and depression. It is beneficial in the case of CR because she experiences chronic pain and has anxiety about her health, which is causing her mood swings.

In behavioral activation, CR will be encouraged to attend to pleasant activities she once enjoyed and engage in regardless of pain. At the same time, relaxation, which includes guided imagery, will reduce her anxiety and painful sensations.

Psychotherapy Plan

• Weekly sessions for four to six weeks, followed by a reevaluation
• Goals:

1. Boost activity participation via behavioral activation.
2. Challenge negative thought patterns related to health and pain.
3. Teach relaxation techniques for pain and anxiety management.

Principles:

• Cognitive Restructuring: Help CR replace negative thoughts with more balanced perspectives.
• Behavioral Activation: Encourage participation in meaningful activities to improve mood and reduce avoidance.
• Relaxation: Use guided imagery and deep breathing to manage anxiety and pain.

Follow-up Plan:

• Weekly tracking of pain and mood using a journal to monitor progress.
• After 4-6 weeks, reassess for possible adjustment to bi-weekly sessions.

Referrals:

• Pain Management Specialist: For chronic pain interventions.
• Psychiatrist: For medication management, especially for bipolar II disorder and panic disorder.
• Support Groups: Consider referrals to chronic pain or mental health support groups to reduce isolation and provide additional coping resources.

I confirm the patient used for this assignment is a patient that was seen and managed by the student at their Meditrek approved clinical site during this quarter course of learning.

Preceptor signature: ________________________________________________________

Date: ________________________

References

Cackovic, C., Nazir, S., & Marwaha, R. (2020). Panic disorder. PubMed; StatPearls Publishing. https://pubmed.ncbi.nlm.nih.gov/28613692/

Elma, Ö., Brain, K., & Dong, H.-J. (2022). The importance of nutrition as a lifestyle factor in chronic pain management: A narrative review. Journal of Clinical Medicine, 11(19), 5950. https://doi.org/10.3390/jcm11195950

Munir, S., & Takov, V. (2022, October 17). Generalized Anxiety Disorder. PubMed; StatPearls Publishing. https://pubmed.ncbi.nlm.nih.gov/28722900/

Office of Disease Prevention and Health Promotion. (2024). Healthy people 2030. Health.gov. https://odphp.health.gov/healthypeople

Vieta, E. (2019). Bipolar II disorder: Frequent, valid, and reliable. The Canadian Journal of Psychiatry, 64(8), 541–543. https://doi.org/10.1177/0706743719855040

White, N., Packard, K., Kalkowski, J., Walters, R., Haddad, A. R., Flecky, K., Rusch, L., Furze, J., Black, L., & Peterson, J. (2022). Improving health through action on economic stability: Results of the finances first randomized controlled trial of financial education and coaching in single mothers of low-income. American Journal of Lifestyle Medicine, 17(3), 155982762110695. https://doi.org/10.1177/15598276211069537

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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.

To Prepare

• Review this week’s Learning Resources and consider the insights they provide about clinical practice guidelines.
• Select a group patient for whom you conducted psychotherapy for a mood disorderduring the last 4 weeks. Create a Comprehensive Psychiatric Evaluation Note on this patient using the template provided in the Learning Resources. There is also a completed template provided as an exemplar and guide. All psychiatric evaluation notes must be signed by your Preceptor. When you submit your note, you should include the complete comprehensive psychiatric evaluation note as a Word document and pdf/images the completed assignment signed by your Preceptor. You must submit your note using Turnitin.
• Please Note: Electronic signatures are not accepted. If both files are not received by the due date, Faculty will deduct points per the Walden Grading Policy.
• Then, based on your evaluation of this patient, develop a video presentation of the case. Plan your presentation using the Assignment rubric and rehearse what you plan to say. Be sure to review the Kalturasupport resources in the Classroom Support Center found by clicking on the Help
• Include at least five scholarly resources to support your assessment and diagnostic reasoning.
• Ensure that you have the appropriate lighting and equipment to record the presentation.

The Assignment
Record yourself presenting the complex case for your clinical patient.

Do not sit and read your written evaluation! The video portion of the assignment is a simulation to demonstrate your ability to succinctly and effectively present a complex case to a colleague for a case consultation. The written portion of this assignment is a simulation for you to demonstrate to the faculty your ability to document the complex case as you would in an electronic medical record. The written portion of the assignment will be used as a guide for faculty to review your video to determine if you are omitting pertinent information or including non-essential information during your case staffing consultation video.

In your presentation:

• Dress professionally and present yourself in a professional manner.
• Display your photo ID at the start of the video when you introduce yourself.
• Ensure that you do not include any information that violates the principles of HIPAA (i.e., don’t use the patient’s name or any other identifying information).
• Present the full complex case study. Be succinct in your presentation, and do not exceed 8 minutes. 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.

By Day 7

• Submit your Video and Comprehensive Psychiatric Evaluation Note. You must submit two files for the evaluation note, including a Word document and scanned pdf/images the completed assignment signed by your Preceptor.

submission information – Part 1: Recording
To submit your video response entry:

• Click on Start Assignment near the top of the page.
• Next, click Text Entry and then click the Embed Kaltura Media button.
• Select your recorded video under My Media.
• Check the box for the End-User License Agreement and select Submit Assignment for review.

submission information – Part 2: Comprehensive Psychiatric Evaluation Note
To submit Part 2 of this Assignment, click on the following link:

• Week 4 Assignment 2, Part 2

Resources:

• DSM-5-TR  text
• Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan & Sadock’s synopsis of psychiatry (11th ed.). WoltersKluwer.
• Zakhari, R. (2020). The psychiatric-mental health nurse practitioner certification review manual. Springer.