NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template

CC (chief complaint): “After taking propranolol, I’ve been experiencing lightheadedness and dizziness. Auvelity also produced upset stomach and nausea.”

HPI:

NE is a 46-year-old female who presents for evaluation of side effects from medications, including dizziness and lightheadedness stemming from propranolol and nausea/upset stomach related to Auvelity; she had been taking this medication almost weekly until discontinuing. NE also stated in her history that she had several thoracic aortic aneurysms, and her Spravato treatment has been paused until cardiology clearance. She is already maintained on Cymbalta for the depression, while a follow-up test on the aneurysm is scheduled for November. Of current concern is the management of depressive and anxiety symptoms without further adverse effects on her physical health.”

Past Psychiatric History:

• General Statement: NE has experienced recurrent depression since receiving the initial diagnosis of what is now recognized as major depressive disorder at the age of thirty. She is also diagnosed with panic disorder and agoraphobia.
• Caregivers (if applicable): None
• Hospitalizations: There were no outpatient psychiatric hospitals in the past.
• Medication trials: NE was previously administered antidepressants and antianxiety medications, including propranolol, which causes lightheadedness or dizziness, and Auvelity, which causes nausea and upset stomach. She is currently taking Cymbalta for depression, and so far, no negative effects have been noticed.
• Psychotherapy or Previous Psychiatric Diagnosis: NE has been using psychotherapy services in her life from a young age but in an irregular manner. She has used cognitive behavioral therapy (CBT) before for panic attacks and agoraphobia but is not in therapy at this time.

Substance Current Use and History: NE denies the use of alcohol, tobacco, or any illicit drugs. She drinks coffee occasionally but does not use it excessively.

Family Psychiatric/Substance Use History: NE’s mother was treated with medication for her history of depression. There is no family history of substance abuse or psychiatric hospitalizations.

Psychosocial History: NE was born and raised in a small town and is the oldest of three siblings. She has two children and has been married for 15 years. NE was an office manager but reported that the depressive and anxiety symptoms have significantly impacted productivity and ability to function at work and home. NE completed a bachelor’s degree in business administration. She enjoys reading and cooking in her free time.

Medical History: Treatment decisions for NE’s thoracic aortic aneurysm are pending cardiology clearance, and the patient is under observation.

• Current Medications:
  • Duloxetine (Cymbalta): Depression and anxiety: 60 mg PO daily.
  • Esketamine (Spravato): Temporarily on hold for cardiology confirmation.
  • Hydroxyzine HCl: 50 mg PO PRN for anxiety.
  • Ondansetron: 4 mg PO PRN for nausea.
• Allergies: NKDA

• Reproductive Hx: The menstrual history of NE is hardly noteworthy. She is not currently pregnant or lactating, and there are no concerns regarding contraception use or sexual health.

ROS:

• GENERAL: No fever, chills, or weight changes. Reports fatigue but attributes this to her depression.
• HEENT: No visual changes, hearing loss, or sore throat.
• SKIN: There is no presence of rashes or changes noted.
• CARDIOVASCULAR: Thoracic aortic aneurysm, experiencing occasional dizziness from propranolol, which has since been discontinued.
• RESPIRATORY: There is no shortness of breath or cough.
• GASTROINTESTINAL: After using Auvelity, which has since been stopped, she had nausea and an upset stomach.
• GENITOURINARY: No burning, urgency, or other issues.
• NEUROLOGICAL: Lightheadedness due to propranolol, no syncope or weakness.
• MUSCULOSKELETAL: There is no joint pain or stiffness.
• HEMATOLOGIC: Easy bruising or bleeding not evident.
• LYMPHATICS: There are no enlarged lymph nodes.
• ENDOCRINOLOGIC: No heat or cold intolerance, polyuria, or polydipsia.

Physical exam: None at the moment

Diagnostic results: Not done

Assessment

Mental Status Examination:

NE appears to be her stated age, is neatly groomed, and has an appropriate appearance. She is “down,” and her affect matches her mood. Speech is typical in volume and rate and is coherent. Thought processes are goal-oriented and logical. No hallucinations, delusions, or other signs of psychosis are present. She refutes any suicidal or homicidal ideation. Insight and judgment are intact. NE is fully oriented to time, place, and person. Memory (recent and remote) and concentration are intact.

Differential Diagnoses:

1. F33.2 Major Depressive Disorder, Recurrent, Severe without Psychotic Features:
   NE’s long-standing history of major depressive disorder (MDD), coupled with current symptoms such as low mood, fatigue, anhedonia, and difficulty concentrating, points to this as the primary diagnosis. The persistence of these symptoms without psychotic features aligns closely with the DSM-5-TR criteria for this diagnosis. NE has been treated for MDD for many years, and her symptoms have fluctuated in severity, with her current medication (Cymbalta) helping to manage them but not fully alleviating her depressive episodes (Marx et al., 2023).
2. F40.01 Agoraphobia with Panic Disorder:
   NE has a well-documented history of agoraphobia, which presents as severe anxiety in crowded or open spaces, leading to avoidance behaviors. She experiences panic attacks in these situations, characterized by palpitations, shortness of breath, and overwhelming fear (Shin et al., 2020). This condition has weakened her capability to function in public spaces and meets the diagnostic criteria necessary from the DSM-5-TR for agoraphobia with panic disorder.
3. F41.0 Panic Disorder (without Agoraphobia):
   Other than agoraphobia, NE also describes panic attacks in places that have no connection with this definition or massive open space and specifies that besides agoraphobia, NE has a panic disorder. These attacks are defined mainly by the features of their development, such as an acute sense of dizziness, palpitations, and the fear of losing control; attacks correspond to the criteria for panic disorder without agoraphobia, according to DSM-V (Papola et al., 2021).

Primary Diagnosis:

• F33.2 Major Depressive Disorder, Recurrent, Severe without Psychotic Features:
  The primary diagnosis is MDD due to the persistent and severe nature of NE’s depressive symptoms, which have been ongoing for years and have greatly impacted her daily functioning. This diagnosis takes precedence due to its chronicity, severity, and the need for careful management with pharmacotherapy and psychotherapy, as noted by Bains and Abdijadid (2023). The other diagnoses, while significant, are secondary to her depression in terms of impact on her overall quality of life.

Reflections:

In a similar evaluation, I would place a greater emphasis on continuous, close monitoring of the patient’s medication side effects, particularly in cases where the patient has a complex medical history, such as NE’s thoracic aortic aneurysm. This would include more frequent follow-up appointments to assess the patient’s response to medication adjustments. Additionally, I would consider collaborating more actively with the patient’s cardiologist to ensure that the psychiatric treatment plan does not interfere with her cardiovascular condition.

In NE’s case, one important social determinant of health is access to healthcare services. Per Healthy People 2030, access to timely and appropriate healthcare, including specialty services such as cardiology and psychiatric care, is essential for optimal health outcomes (US Department of Health and Human Services, 2020). NE’s delayed access to cardiology services has affected her ability to continue Spravato treatment, which has been a crucial part of her depression management. This underscores the importance of ensuring that patients with complex medical needs can access all necessary services without delays to avoid gaps in care.

Health Promotion Activity

As a future advanced provider, I would recommend engaging NE in regular physical activity as a health promotion activity. Exercise has been shown to improve mood and decrease symptoms of depression and anxiety (Smith & Merwin, 2021). Since NE is already on a pharmacological regimen, incorporating a structured exercise program would complement her treatment plan by improving both her physical and mental well-being.

Patient Education Consideration

One patient education consideration for NE would be informing her about the importance of adherence to follow-up appointments with both psychiatric and cardiology providers. Explaining the significance of coordination between her mental and physical health treatments can empower NE to prioritize and seek care promptly, thus reducing potential health disparities and avoiding worsening her conditions (Singh et al., 2022). Encouraging her to take an active role in managing both her psychiatric and physical health will contribute to improved health outcomes and reduce the risk of complications.

Critical Thinking Reflection

This case demonstrates the importance of viewing psychiatric conditions through a holistic lens, particularly when dealing with patients who have significant medical comorbidities. Balancing psychiatric and medical treatments, such as NE’s depression and her aneurysm, requires careful consideration to avoid adverse effects and ensure optimal health outcomes. Moving forward, ensuring that healthcare systems are better integrated and more accessible will be key to reducing inequities and improving patient outcomes in psychiatric care.

PRECEPTOR VERIFICATION:

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

Bains, N., & Abdijadid, S. (2023, April 10). Major depressive disorder. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK559078/

Marx, W., Penninx, B. W. J. H., Solmi, M., Furukawa, T. A., Firth, J., Carvalho, A. F., & Berk, M. (2023). Major depressive disorder. Nature Reviews Disease Primers, 9(1). https://doi.org/10.1038/s41572-023-00454-1

Papola, D., Ostuzzi, G., Tedeschi, F., Gastaldon, C., Purgato, M., Del Giovane, C., Pompoli, A., Pauley, D., Karyotaki, E., Sijbrandij, M., Furukawa, T. A., Cuijpers, P., & Barbui, C. (2021). Comparative efficacy and acceptability of psychotherapies for panic disorder with or without agoraphobia: systematic review and network meta-analysis of randomised controlled trials. The British Journal of Psychiatry, 221(3), 1–13. https://doi.org/10.1192/bjp.2021.148

Shin, J., Park, D.-H., Ryu, S.-H., Ha, J. H., Kim, S. M., & Jeon, H. J. (2020). Clinical implications of agoraphobia in patients with panic disorder. Medicine, 99(30). https://doi.org/10.1097/MD.0000000000021414

Singh, V., Kumar, A., & Gupta, S. (2022). Mental Health Prevention and Promotion—a Narrative Review. Frontiers in Psychiatry, 13(13). https://doi.org/10.3389/fpsyt.2022.898009

Smith, P. J., & Merwin, R. M. (2021). The Role of Exercise in Management of Mental Health Disorders: An Integrative Review. Annual Review of Medicine, 72(1), 45–62. https://doi.org/10.1146/annurev-med-060619-022943

US Department of Health and Human Services. (2020). Access to Health Services . Healthy People 2030. https://health.gov/healthypeople/priority-areas/social-determinants-health/literature-summaries/access-health-services

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Comprehensive Psychiatric Evaluation and Patient, Video Case Presentation

For this Assignment, you will document information about a patient that you examined during the last 3 weeks, using the Comprehensive Psychiatric Evaluation Template provided. You will then use this note to develop and record a case presentation for this patient. Be sure to incorporate any feedback you received on your Week 3 and Week 6 case presentations into this final presentation for the course.

To Prepare

• Review this week’s Learning Resources and consider the insights they provide. Also review the Kaltura Media resource in the Classroom Support Center area (accessed via the Help button).
• Select a patient that you examined during the last 3 weeks who presented with a disorder for which you have not already conducted an evaluation in Weeks 3 or 6. (For instance, if you selected a patient with OCD in Week 6, you must choose a patient with another type of disorder for this week.) 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 by your Preceptor. When you submit your document, you should include the complete Comprehensive Psychiatric Evaluation as a Word document, and the completed assignment signed by your Preceptor. You must submit your document using Turn It In. Please Note: Electronic signatures are not accepted. If both files are not received by the due date, Faculty will deduct points per the Walden Late Policies.
• Then, based on your evaluation of this patient, develop a video case presentation that includes chief complaint; history of present illness; any pertinent past psychiatric, substance use, medical, social, 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.
• Ensure that you have the appropriate lighting and equipment to record the presentation.

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 case. Include chief complaint; history of present illness; any pertinent past psychiatric, substance use, medical, social, family history; most recent mental status exam; and current psychiatric diagnosis including differentials that were ruled out.
• Report normal diagnostic results as the name of the test and “normal” (rather than specific value). Abnormal results should be reported as a specific value.
• Be succinct in your presentation, and do not exceed 8 minutes. Address the following:
  • Subjective: What details did the patient provide regarding their personal and medical history? What are their symptoms of concern? How long have they been experiencing them, and what is the severity? How are their symptoms impacting their functioning?
  • Objective: What observations did you make during the interview and review of systems?
  • Assessment: What were your differential diagnoses? Provide a minimum of three (3) possible diagnoses. List them from highest to lowest priority. What was your primary diagnosis, and why?
  • 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 Case Presentation.

Note: In Week 9: Assignment 2, Part 2 you will submit two (2) files for the Comprehensive Psychiatric Evaluation, including a Word document and scanned PDF/images of the completed assignment signed by your Preceptor.

Client’s Notes:

• Hello, please use three diagnoses that are different from that of order 58234..Please follow all information and please remember this is for my PMHNP course.
• I have provided a patient that you will use for this assignment and a little sketch about the patient and possibly some of the differential diagnosis out of the three. Thank you.
  • Please if you can put another differential diagnosis other than MDD that will be fine, if not work with the two i provided and add extra one to make it the required 3 working diagnosis
    • The patient, NE is a 46 year old female.She reported experiencing nausea and an upset stomach after taking Auvelity for almost a week, and dizziness and lightheadedness from propranolol, likely due to low blood pressure. They have a thoracic aortic aneurysm and are awaiting cardiologist clearance to resume Spravato treatment. Auvelity and propranolol were discontinued due to adverse effects, and the patient will continue Cymbalta. A follow-up test for the aneurysm is scheduled for November .
      • Differential diagnosis so far ;
        • (F33.2) Major depressive disorder, recurrent severe without psychotic features
        • (F40.01) Agoraphobia with panic disorder
      • Medication
        • Duloxetine HCl (Cymbalta) 60 MG Oral Capsule Delayed Release Particles
        • Esketamine HCl (Spravato (56 MG Dose)) 28 MG/DEVICE Nasal Solution Therapy Pack
        • Hydroxyzine HCl (hydrOXYzine HCl) 50 MG Oral Tablet
        • Ondansetron HCl 4 MG Oral Tablet

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.