Assignment : Comprehensive Psychiatric Evaluation and Patient Case Presentation 

Assignment : Comprehensive Psychiatric Evaluation and Patient Case Presentation 

Assignment : Comprehensive Psychiatric Evaluation and Patient Case Presentation 

NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template Sample

CC (chief complaint): Recurrent flashbacks of warfare events

HPI: FP is a 27-year-old white male presenting to the psychiatric clinic for assessment. He presents with complaints of recurrent flashbacks of warfare events that he witnessed during his longstanding active duty as a combat veteran which he left a year ago. These flashbacks include distressing vivid incidences of his colleagues being killed and are triggered by cues such as sudden loud noises, harmless explosions, and specific smells. Whenever encountered, these cues trigger emotional and physical distress in the patient such as shaking, shortness of breath, sweating, fear and attempts to take cover from the re-experienced events. The patient also experiences nightmares that disturb his sleep. He is also easily startled. He also stays in his room most time and avoids social situations in an attempt to minimize exposure to the triggering cues. He is frequently preoccupied with past traumatic events.

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Past Psychiatric History:

• General Statement: The patient has not been on any psychiatric treatment and this was his first contact with mental health services.
• Caregivers (if applicable): He lives with his fiancée who recommended his evaluation and whom he is yet to marry.
• Hospitalizations: There are no past psychiatric admissions.
• Medication trials: The patient has not been on any medication trials.
• Psychotherapy or Previous Psychiatric Diagnosis: The are no reported past psychotherapeutic interventions or psychiatric diagnoses.

Substance Current Use and History: The patient denies any history of alcohol consumption, smoking, or use of any other substance of abuse.

Family Psychiatric/Substance Use History: His grandfather had depression after serving in the military as well. His father has a chronic heavy alcohol user.

Psychosocial History: The patient was raised by both his parents under tough circumstances due to poverty. He is a second born with two other siblings, one elder sister, and one younger brother. He currently stays with his fiancée whom they soon get married. They live away from home due to occupational reasons. His educational level is high school before joining the military. He is currently a salesperson. He has no legal issues or forensic history with the authorities.

Medical History:

• Current Medications: The patient is not on any prescription medication.
• Allergies: The patient is asthmatic and experiences seasonal allergies. There is no reported food or drug allergy.

• Reproductive Hx: The patient currently has no children but intends to soon once he gets married.

ROS:

• GENERAL: There is no reported weight loss, fever, or body weakness.
• HEENT: Patient denies photophobia, loss of vision, hearing loss, dysphagia, sore throat, or nasal congestion.
• SKIN: There is no reported pruritus or skin rash.
• CARDIOVASCULAR: There are no chest pains/discomfort, palpitations, easy fatigability, or lower limb edema.
• RESPIRATORY: There is no reported difficulty in breathing, cough, chest pain, or wheezing.
• GASTROINTESTINAL: The denies any anorexia, abdominal pain, nausea, vomiting, diarrhea, constipation, or blood in the stool.
• GENITOURINARY: There are no reported discomfort or burning sensation on urination, no blood in urine, and no increased frequency.
• NEUROLOGICAL: Patient denies headaches, seizures, focal neurological deficits, dizziness, or incontinence.
• MUSCULOSKELETAL: There is no myalgia, arthralgia, joint stiffness, or swelling.
• HEMATOLOGIC: The patient denies bleeding tendency or anemia.
• LYMPHATICS: There are no reported enlarged lymph nodes or splenomegaly.
• ENDOCRINOLOGIC: There is no polyuria, polydipsia, polyphagia, intolerance to cold or heat, or increased sweating.

Physical exam:

Vital signs: Blood pressure 134/80 mmHg, Pulse rate 84, Temperature 97.4, Height 5’8, Weight 167 lbs

General: The patient appears anxious but is otherwise in good general health.

HEENT: The head is atraumatic, the pupils are equally and bilaterally reactive to light, the nose is clear, the ear canal is clear and the tympanic membrane is intact, the oral hygiene is good with no inflammation of the throat.

Neck: There is no cervical lymphadenopathy, no raised jugular venous pressure, and no other abnormal masses.

Chest/Lungs: There is no obvious chest deformity. Chest movements are symmetrical. On auscultation, normal vesicular breath sounds were heard. There are no wheezes or stridor. Vocal resonance is normal.

Heart/Peripheral Vascular: The precordium exhibits normal cardiac activity. Tje first and second heart sounds were heard with no murmurs, thrills,  or heaves. The pulse is regular and of good volume.

Abdomen: The abdomen is of normal fullness with no tenderness, masses, or organomegaly.

Genital/Rectal: Digital rectal examination showed normal anal tone and smooth rectal mucosa with no blood on the examining finger.

Musculoskeletal: There is no muscle or joint tenderness, no joint swelling, no stiffness, and no limitations in the range of motion.

Neurological: There is an intact cranial nerves examination. Sensory and motor examination are also normal with no neurological deficits. is normal. 

Skin: The skin is intact with no eruptions.

Diagnostic results:

A toxicology screen for any substance of abuse was negative.

Thyroid function tests showed normal ranges of TSH, T3, and T4.

Blood cultures were negative for microorganisms.

A head CT scan had no abnormalities.

Assessment

Mental Status Examination: The patient is a 27-year-old white male who appears his stated age. He is well-groomed and appropriately dressed. He is alert and maintains eye contact with the examiner though he appears anxious and hyper-vigilant at times. He is not agitated and adequately cooperates with the examiner. His orientation to time, place, and person is intact. His speech is of normal rate and is clear and coherent. He has a depressed mood that is congruent with his affect. His thought process is logical. His thought content has negative beliefs and worries about a recurrence of the war zone traumatic events. He exhibits no flight of ideas. He has no suicidal thoughts or ideations with no intention of harming himself or others. He experiences flashbacks of past traumatic events. He has neither auditory nor visual hallucinations. He has intact immediate, recent, remote, and long-term memories. His concentration is good. He is insightful about his condition. His judgment is poor due to the fear that is out of proportion with the perceived threat making him housebound. 

Differential Diagnoses:

1. Post-traumatic stress disorder (PTSD): This is the most probable diagnosis for this patient. This is because the patient has prior exposure to distressing near-death war zone experiences. He also presents with typical manifestations such as re-experience of past distressing events, nightmares, flashbacks, sleep disturbance, hypervigilance, and avoidance of trauma-related cues and triggers (Mann et al., 2022). The patient stays in his room in an attempt to avoid triggering situations. The patient also experiences physical and emotional reactions to triggering cues.
2. Social anxiety disorder: This is the other possible differential diagnosis. The patient’s tendency to avoid social situations and stay in his room instead may be indicative of this disorder (Leigh et al., 2018). The other physiological symptoms of shortness of breath, sweating, and tremors are also present in social anxiety disorder. These symptoms are, however, more likely to result from the patient’s post-traumatic stress disorder.
3. Depressive illness: The patient is likely suffering from a depressive illness. This is because of the predisposing stressful life events in the war zone and the features of disturbed sleep and depressed mood. He, however, does not exhibit other features such as a lack of energy, lack of motivation, appetite changes, suicidal tendencies, and feelings of guilt (Christensen et al., 2020). Depressive illness can co-exist with post-traumatic stress disorder thus this diagnosis should be considered.

Reflections: The history and physical and mental state assessments were comprehensive and adequate to work up an accurate diagnosis. The examiner was patient with the patient as he explained his experiences in detail. The practitioner was able to elicit relevant additional information such as typical post-traumatic stress disorder features of nightmares and trauma-related triggering cues. The initial creation of rapport with the patient enabled the patient to be open and truthful to the examiner and even revealed that he had not shared his experiences with any other person. The ethical principles of patient autonomy, beneficence, non-maleficence, justice, privacy, and confidentiality should be maintained throughout the process of patient management to promote patient satisfaction and the quality of care offered. Post-traumatic stress disorder can be distressing to the patient thus there is a need for supportive psychotherapeutic interventions such as group therapy and family therapy. This will ensure that the patient has enough support.

References

Christensen, M. C., Wong, C. M., & Baune, B. T. (2020). Symptoms of major depressive disorder and their impact on psychosocial functioning in the different phases of the disease: Do the perspectives of patients and healthcare providers differ? Frontiers in Psychiatry, 11. https://doi.org/10.3389/fpsyt.2020.00280

Leigh, E., & Clark, D. M. (2018). Understanding social anxiety disorder in adolescents and improving treatment outcomes: Applying the cognitive model of Clark and Wells (1995). Clinical Child and Family Psychology Review, 21(3), 388–414. https://doi.org/10.1007/s10567-018-0258-5

Mann, S. K., & Marwaha, R. (2022). Posttraumatic Stress Disorder. In StatPearls. StatPearls Publishing.

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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 Uploader resource in the left-hand navigation of the classroom for help creating your self-recorded Kaltura video.
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, 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. 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.
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.