Comprehensive Psychiatric Evaluation Template
CC (chief complaint): K.C. is a 32-year-old African American female who was brought to the outpatient department with troubled speech and anhedonia. The patient also seems restless and has notable hyperventilation and notable perspiration. Collaborative history from the parents reveals that the patient has been exhibiting a lack of motivation, is easily fatigued, lacks interest, and sometimes looks sad.
HPI: History of the presenting illness reveals that the patient started having paucity of speech and anhedonia 24 hours before the visitation. The restlessness has been on and off but became worse the morning of the hospital visitation. The patient is sweaty, a symptom she has been having for a week now. The lack of interest, lack of motivation, and feeling of sadness started two weeks before visitation.
Past Psychiatric History:
General Statement: the patient was initially diagnosed with Schizophrenia at age 26. She has since been on treatment with various antipsychotic medications.
Hospitalizations: The patient has never had any significant hospitalizations attributable to psychiatric diagnoses. However, the patient was briefly hospitalized for treatment of haloperidol-induced catatonia during her initial phase of treatment.
Medication trials: Medical trials revealed that the patient was started on haloperidol briefly after accepting treatment. She was then switched to olanzapine and later to the current medication she is currently on. Her caregivers report that K.C. experienced acute dystonic reactions on haloperidol use, a reaction that prompted brief hospitalization and consequential treatment with benztropine. The switch to olanzapine was also not sustainable due to the high cost of the medication. The patient has reportedly used many unidentified over-the-counter medicines to help with her sleep and alleviate the constant headaches she often complains about.
Psychotherapy or Previous Psychiatric Diagnosis: The patient’s psychiatric history reveals that she had been diagnosed with Schizophrenia 5 years ago after a significant history of drug abuse. The patient has had two previous psychiatric disorders, one of which prompted psychotherapy. At 21 years, K.C was suspected to be having a mild depressive disorder, a suspicion that was confirmed by a psychiatrist. This mild depression was later linked to a life stressor that she was undergoing during that moment. This was, however, successfully managed by counseling from both her doctor and her parents. K.C. has also had previous intermittent anxiety attacks. These episodes most often occurred during her schooling days but did not exhibit any pattern that would link these episodes to any of the potential school stressors. The patient has never had any hospitalizations attributable to psychiatric diagnoses.
Substance Current Use and History: Substance use history reveals previous and current use of several drugs. K.C. has a previous use of alcohol, cigarettes, and cannabis use. She reports to have used cannabis for close to 4 years but stopped upon being diagnosed with Schizophrenia. She is also a binge alcohol drinker and occasional cigarette smoker. She attributes her behavior to peer influence and a wrong social group. She has since seized any form of substance use.
Family Psychiatric/Substance Use History: Family history reveals no traceable existence of any schizophreniform disorder in the family. There is, however, evidence of substance use, with both parents reporting to being occasional smokers and alcohol drinkers.
Psychosocial History: Social history reveals K.C. was born 32 years ago and still lives in Akron, OH. She is the firstborn in a family of three. Her brother and sister are all alive and doing well. Her parents are still married. Her mother is alive and doing well. Her father is also well but is, however, ill and has been battling diabetes and hypertension for ten years now. K.C. is a university graduate who likes swimming and reading books. She is not married but has been in a relationship with her boyfriend for two years now. K.C. is a former factory worker who lost her job due to missed work hours attributable to depression. She currently works as a shop assistant. K.C. has been involved in one street violence in the past that led to her hospitalization. Legal pursuit of this matter revealed that she was just a victim of this incident, and therefore, no legal action was taken against her.
Medical History: The patient’s medical history reveals that she has had two major hospitalizations that resulted from drug use. The first hospitalization was attributable to excessive alcohol use, whereas the second hospitalization resulted from injuries sustained during a brawl at a party she attended. Investigations into the street brawl that caused her injuries revealed cannabis use. The patient has had multiple attempts to commit suicide. These episodes were particularly more during her initial stages of treatment. She has no underlying medical condition and is currently on several antipsychotic medications.
Current Medications: She is currently on aripiprazole 15mg O.D., alprazolam 1mg O.D., zolpidem 5mg PO OD NOCTE, sertraline 20mg P.O. 6 hourly. She occasionally takes acetaminophen 1000mg 8 hourly when experiencing headaches or body aches.
Allergies: K.C. has no known allergies to any of the medications she is taking.
Reproductive Hx: Reproductive history reveals that the patient has a regular menstrual cycle, with her last menstrual date being approximately two weeks ago. She is not on any contraceptive and engages in vaginal intercourse with her boyfriend.
ROS:
GENERAL: The client has no evidence of weight loss, weakness, or fatigue
HEENT: Examination reveals visual and auditory acuity. There is no evidence of sore throat, sneezing, or running nose.
SKIN: Skin examination reveals normal skin that is warm to the touch, has good skin turgor, and has no abnormal pigmentation.
CARDIOVASCULAR: Cardiovascular examination reveals a blood pressure of 145/87 and a pulse rate of 75 bpm. There are diffuse visible palpitations from her neck region. The patient reports no chest pain or any form of chest discomfort.
RESPIRATORY: respiratory exam reveals no evidence of dyspnea and no cough or sputum production
GASTROINTESTINAL: Gastrointestinal examination reveals the absence of nausea and/or vomiting, no abdominal discomfort, and absence of anorexia.
GENITOURINARY: Genitourinary examination reveals normal urination with no urgency, urinary frequency, burning sensation upon urination, normal urine color, and no odd odor.
NEUROLOGICAL: Neurologic examination reveals slight headache, no dizziness, no form of paralysis or numbness of extremities.
MUSCULOSKELETAL: Musculoskeletal examination reveals no muscle, joint, or back pain and no stiffness.
HEMATOLOGIC: Hematologic examination reveals no bleeding or bruising and that the patient is not anemic.
LYMPHATICS: Lymphatic system exam reveals no lymph swelling and no history of splenectomy.
ENDOCRINOLOGIC: An endocrinology exam reveals visible perspiration but the absence of polydipsia or polyuria.
Diagnostic results: Diagnostic results that were utilized in the diagnosis included an MRI and C.T. scan as well as a blood test. The MRI and C.T. scans were conducted to rule out any physical injuries that may be causing the symptoms. C.T. and MRI scans were all negative for any involvement of physical injury. A blood test was also done to eliminate drug and substance use as a causative factor for the presenting symptoms. Test results were negative of any drug of abuse.
Assessment
Mental Status Examination: A mental examination of the patient revealed the patient was appropriately groomed when coming to the clinic and was accompanied by her parents. The patient is properly dressed for the occasion and well-orientated to the place and weather. The patient is also able to express herself and denies any current suicidal ideation. The patient appears sad and a little depressed.
Differential Diagnoses: Differential diagnoses of this patient include Schizophrenia, anxiety, and major depressive disorders. Schizophrenia is a psychiatric disorder characterized by marked disturbances in thought processes, delusions, and hallucinations. The symptoms that the patient presented with were consistent with the symptoms of Schizophrenia that are listed in the DSM-5. A positive diagnosis of Schizophrenia is made when two or more of the classic schizophrenic symptoms appear in an individual within one month. These symptoms include delusions, hallucinations, catatonic behavior, and negative symptoms such as restlessness, lack of motivation, and paucity of speech (Stępnicki et al., 2018). This patient presented with negative symptoms such as anhedonia and troubled speech. The occurrence of these symptoms at the same time confirmed the diagnosis of Schizophrenia.
Anxiety disorders are characterized by the increased feeling of worry or fear of otherwise normal life situations. DSM-5 outlines the criteria for diagnosing anxiety disorders. According to DSM5, anxiety is only positive when the patient presents with any of the classic symptoms of general anxiety disorders within six months of hospital visitation. These symptoms include excessive worry about various life situations, restlessness, irritability, fatigue, insomnia, and increased muscle aches (Spence & Rapee, 2016). This patient presented with restlessness, a report of insomnia that prompted her use of hypnotic drugs, irritability, and fatigue. These symptoms are consistent with those of general anxiety disorders as outlined in the DSM-5 manual and confirm the diagnosis of anxiety disorder.
Major depressive disorder is a mental condition characterized by a persistent feeling of sadness and loss of interest in life activities. This patient had an occasional feeling of sadness and sometimes exhibited a lack of motivation and loss of interest. However, these two symptoms alone do not meet the criteria described in the DSM 5 for the diagnosis of major depressive disorder. The DSM 5 outlines the criteria for diagnosing major depressive disorders and that the patient must experience five or more of the symptoms listed for this disorder within two weeks. These symptoms include depressed mood for the better part of the day for many days, significant weight loss or weight gain, lack of concentration, fatigue, lack of interest in life activities, and withdrawal, among others (Riaz, 2018). This patient does not meet the criteria for a positive diagnosis of major depressive disorders as per the DSM 5.
Reflections: This patient case study is a replica of how psychiatric disorders are managed. Effective management is dependent on an accurate and comprehensive evaluation of the patient. I agree with my preceptor’s assessment and diagnostic impression of the patient. His findings were consistent with the knowledge I obtained from class. The case accorded me an opportunity to reinforce my skills in patient evaluation and enabled me to appreciate the complexities presented with managing psychiatric patients. In practice, I would reinforce the significance of caregivers in the management of psychiatric management by encouraging caregivers to actively participate in patient management by assuming the role of patient monitoring.
Psychiatric patients reserve the right to be treated as human beings, not by their incarcerations. It is for this reason that they should be treated respectfully. Ethical principles of respect and doing good should also apply to them. Psychiatric disorders are relatively prevalent in the U.S. Recent data suggest that about half of the American population is likely to experience at least one type of psychiatric disorder (Auerbach et al., 2018). According to Lin & Lane, 2019, the effectiveness of psychiatric disorders management is, however, determined by the accurate and prompt diagnosis of these disorders and consequent initiation of therapy. Therefore, health promotional activities may be necessary for reducing the occurrence of various mental disorders. The public should be educated on the predisposing factors to some mental disorders. Cannabis use, for instance, has been linked with the development of Schizophrenia (Tekin Uludag & Gulenc, 2016). Other environmental factors that increase the risk of developing Schizophrenia include maternal malnutrition and preeclampsia, among others. Educating the public on such issues may reduce the propensity to develop Schizophrenia in the future.
References
Auerbach, R., Mortier, P., Bruffaerts, R., Alonso, J., Benjet, C., & Cuijpers, P. et al. (2018). 19.1 World Health Organization World Mental Health Surveys International College Student Project (WMH-ICS): Prevalence and Distribution of Mental Disorders. Journal Of The American Academy Of Child & Adolescent Psychiatry, 57(10), S297. https://doi.org/10.1016/j.jaac.2018.07.723
Lin, C., & Lane, H. (2019). Early Identification and Intervention of Schizophrenia: Insight From Hypotheses of Glutamate Dysfunction and Oxidative Stress. Frontiers In Psychiatry, 10. https://doi.org/10.3389/fpsyt.2019.00093
Riaz, O. (2018). Major Depressive Disorder and the “Leaky Gut” Post Cholecystectomy. Medical Journal Of Clinical Trials & Case Studies, 2(11). https://doi.org/10.23880/mjccs-16000187
Spence, S., & Rapee, R. (2016). The etiology of social anxiety disorder: An evidence-based model. Behavior Research And Therapy, 86, 50-67. https://doi.org/10.1016/j.brat.2016.06.007
Stępnicki, P., Kondej, M., & Kaczor, A. (2018). Current Concepts and Treatments of Schizophrenia. Molecules, 23(8), 2087. https://doi.org/10.3390/molecules23082087
Tekin Uludag, Y., & Gulenc, G. (2016). Prevalence of Substance Use in Patients Diagnosed with Schizophrenia. Noro Psikiyatri Arsivi, 53(1), 4-11. https://doi.org/10.5152/
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Question 
Conduct a Comprehensive Psychiatric Evaluation on this patient using the template provided in the Learning Resources. There is also a completed exemplar document in the Learning Resources so that you can see an example of the types of information a completed evaluation document should contain. All psychiatric evaluations must be signed, and each page must be initialed by your Preceptor. When you submit your document, you should include the complete Comprehensive Psychiatric Evaluation as a Word document, as well as a PDF/images of each page that is initialed and signed by your Preceptor. You must submit your document using SafeAssign.
Comprehensive Psychiatric Evaluation Template
I will be doing a presentation, based on my progress note of this patient, that includes chief complaint; history of present illness; any pertinent past psychiatric, substance use, medical, social, and family history; most recent mental status exam; and current psychiatric diagnosis, including differentials that were ruled out.
Include at least five (5) scholarly resources to support your assessment and diagnostic reasoning.