Comprehensive Psychiatric Evaluation Note and Patient Case Paper

Comprehensive Psychiatric Evaluation Note and Patient Case Paper

Comprehensive Psychiatric Evaluation Note and Patient Case Paper


CC (chief complaint): “I have excessive anxiety after losing my job.”


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P.B is a 27-year-old White female client who presented with complaints of developing marked distress after losing her job in one of the largest auditing firms in the country. The firm had a retrenchment and was one of the 20 employees who lost their jobs. She states that she experienced a hard time adjusting to life after the job loss and considers the loss a major failure in her life. She also feels guilty for disappointing her uncle, who helped her get the job. P.B mentioned that in the past four months, she has been having excessive worry and anxiety, sleeping difficulties, and is persistently angry. Although she got a new job two weeks ago, she feels trapped and isolated and does not like the job. This has resulted in poor concentration levels, and she has not been performing compared to her previous job. Furthermore, she reports feeling demoralized and helpless, and her self-esteem has declined. She takes a couple of beers to help alleviate the anxiety and forget about her failure.

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Substance Current Use: Takes 4-5 beers per day. Smokes ½ PPD and recreational marijuana. Denies other illicit drug use.

Medical History:

  • Reproductive Hx: None


  • GENERAL: Positive for appetite loss and weight loss. Denies fever, chills, or fatigue.
  • HEENT: Negative for visual changes, eye pain, ear pain/discharge, rhinorrhea, sneezing, or swallowing difficulties.
  • SKIN: Negative for rashes, discoloration, or bruises
  • CARDIOVASCULAR: Negative for dyspnea, neck distension, or edema.
  • RESPIRATORY: Negative for SOB, wheezing, or productive cough.
  • GASTROINTESTINAL: Negative for nausea, vomiting, abdominal discomfort, diarrhea, or constipation.
  • GENITOURINARY: Negative for dysuria, abnormal vaginal discharge, urinary urgency, or frequency.
  • NEUROLOGICAL: Negative for headache, dizziness, tingling sensations, or muscle weakness.
  • MUSCULOSKELETAL: Negative for joint stiffness, joint pain, or muscle pain.
  • HEMATOLOGIC: Negative for bleeding.
  • LYMPHATICS: Negative for swollen lymph nodes.
  • ENDOCRINOLOGIC: Negative for excessive sweating, heat/cold intolerance, or acute thirst.


Diagnostic results: No results available.


Mental Status Examination:

The client is well-groomed and appropriately dressed. She is alert and oriented to person, place, time, and event. She has clear speech and maintains adequate eye contact throughout the session. Her self-reported mood is anxious, and affect is appropriate. She demonstrates a coherent and goal-directed thought process. No obvious obsessions, phobias, hallucinations, delusions, or suicidal ideations. Her short-term and long-term memory is intact. She demonstrates good judgment and abstract reasoning.

Diagnostic Impression:

Adjustment Disorder with Anxiety: Adjustment Disorder manifest with behavioral or emotional symptoms connected to an identifiable stressor. The symptoms occur within three months of the beginning of the stressor (APA, 2013). The DSM-V criteria for the diagnosis of Adjustment disorder require the presence of at least one of the following: Distress that is out of proportion with the expected reactions to the stressor; Clinical symptoms that result in severe distress and impairment in functioning; Distress and impairment associated with the stressor rather than the escalation of existing mental health disorders (APA, 2013; O’Donnell et al., 2019). Adjustment Disorder with Anxiety was the primary diagnosis based on the client’s excessive anxiety related to the stressor (job loss). The anxiety has led to a disruption in social functioning and occupational impairment.

Generalized Anxiety Disorder (GAD): GAD presents with excessive anxiety and worries about various things occurring more days than not for at least six months. The unwarranted anxiety and worry are associated with at least three of the following: Restlessness or feeling keyed up or on edge; concentration difficulties or the mind going blank, easy fatigue, irritability, sleep disturbance, and muscle tension (APA, 2013; Ströhle et al., 2018). GAD is a differential diagnosis owing to the client’s excessive anxiety, concentration difficulties, sleep disturbances, and persistent anger. However, the client’s anger is attributed to a particular stressor (job loss), making GAD an unlikely primary diagnosis.  

Major Depressive Disorder (MDD): MDD is marked by a sad/tearful/ depressed mood or lack of interest in most activities. This is accompanied by at least four of the following: appetite changes, significant weight changes, sleep disturbances, fatigue, diminished energy levels, feelings of worthlessness, indecisiveness, psychomotor agitation, and suicidal ideation or recurrent thoughts of death ( APA, 2013; Christensen et al., 2020). The client’s lack of interest in work, irritable mood, feels helpless, concentration difficulties, insomnia, loss of appetite, and weight loss, make MDD a differential diagnosis.


I agree with the preceptor’s diagnosis of Adjustment Disorder with Anxiety since the client’s anxiety symptoms are attributed to difficulties adjusting after job loss. I have learned that when the stressor is eliminated in individuals with Adjustment disorder, the person begins to adjust and cope, and the symptoms subside within six months (Zelviene & Kazlauskas, 2018). In a different situation, I would measure the patient’s anxiety using GAD-7 to assess the severity of symptoms and guide the treatment plan. Beneficence and nonmaleficence should be upheld by ensuring that the treatment interventions have been established as effective and safe in treating patients with Adjustment Disorders.   

Case Formulation and Treatment Plan: 

The patient will be initiated on cognitive-behavioral therapy (CBT) to help her to identify and reframe the meaning of the stressor. Supportive psychotherapy will also be incorporated to help manage anxiety (Zelviene & Kazlauskas, 2018).


American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th Ed.). Washington, DC: Author.

Christensen, M. C., Wong, C. M. J., & 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, 280.

O’Donnell, M. L., Agathos, J. A., Metcalf, O., Gibson, K., & Lau, W. (2019). Adjustment Disorder: Current Developments and Future Directions. International journal of environmental research and public health, 16(14), 2537.

Ströhle, A., Gensichen, J., & Domschke, K. (2018). The Diagnosis and Treatment of Anxiety Disorders. Deutsches Arzteblatt international, 155(37), 611–620.

Zelviene, P., & Kazlauskas, E. (2018). Adjustment disorder: current perspectives. Neuropsychiatric disease and treatment, 14, 375–381.

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Assignment 2: Focused SOAP Note and Patient Case Presentation

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Psychiatric notes are a way to reflect on your practicum experiences and connect the experiences to the learning you gain from your weekly Learning Resources. Focused SOAP 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 during the last 4 weeks, using the Focused SOAP Note Template provided. You will then use this note to develop and record a case presentation for this patient.

To Prepare
Review the Kaltura Media Uploader resource for help creating your self-recorded Kaltura video

Select an adult patient that you examined during the last 4 weeks who presented with a disorder other than the disorder present in your Week 3 Case Presentation.
Create a Focused SOAP Note on this patient using the template provided in the Learning Resources. There is also a completed Focused SOAP Note Exemplar provided to serve as a guide to assignment expectations.
Please Note:
All SOAP notes must be signed, and each page must be initialed by your Preceptor.
Note: Electronic signatures are not accepted.
When you submit your note, you should include the complete focused SOAP note as a Word document and PDF/images of each page that is initialed and signed by your Preceptor.
You must submit your SOAP note using SafeAssign.
Note: If both files are not received by the due date, faculty will deduct points per the Walden Grading Policy.
Then, based on your SOAP note of this patient, develop a video case study presentation. Take time to practice your presentation before you record.
Include at least five scholarly resources to support your assessment, diagnosis, and treatment planning.
Ensure that you have the appropriate lighting and equipment to record the presentation.

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