Case scenario

W S. is a 36-year-old African American male who presents to the clinic for follow-up psychiatric evaluation and medication management with the diagnosis of unspecified depressive disorder and Alcohol/Ecstasy use. Chief complaints: “I’m here for a follow-up.” The patient presents restless, with euthymic mood and affects. He presents with fair insight and judgment. There was no display of psychosis. He reports no significant issues with sleep, appetite, or energy levels. No display of emotional or perpetual disturbance. The thought process is clear and coherent, and the content does not reveal delusion, paranoia, or suicidal ideations. He reports, “my anxiety is a bit worse; I just lost my dad, and I am down a lot lately.” He stated that his current psychotropic has been working for him, but he needs some therapy/counseling due to the recent death in the family. The patient reports having the urge to drink again since this past event in the family. The patient is single but in a relationship. He lives with a friend and renting. Denies any past inpatient or outpatient hospitalization. Denies any past history of family psychiatric illnesses or substance abuse.

Assessment diagnosis: Unspecified depressive disorder, substance abuse disorder, Alcohol abuse, anxiety disorder

Medication: Remeron 30mg PO QHS, Celexa 20 mg PO Q AM, Zoloft 25 mg PO Q daily.

Treatment Plan: The plan is to continue with the current medications and referral for therapy.

The next appointment is to be scheduled in 1 month.

Classroom Productions Links to an external site.. (Producer). (2016). Impulse and conduct disorders [Video]. Walden University.

Professor Hartung. (2020). Multisystemic therapy (MST) for at-risk youth and juveniles informational webinar Links to an external site.[Video]. YouTube. https://www.youtube.com/watch?v=yHbTEWCDlpE

INSTRUCTIONS ON HOW TO USE EXEMPLAR AND TEMPLATE—READ CAREFULLY
If you are struggling with the format or remembering what to include, follow the Comprehensive Psychiatric Evaluation Template AND the Rubric as your guide. It is also helpful to review the rubric in detail in order not to lose points unnecessarily because you missed something required. Below highlights by category are taken directly from the grading rubric for the assignments. After reviewing full details of the rubric, you can use it as a guide.
In the Subjective section, provide:
• Chief complaint
• History of present illness (HPI)
• Past psychiatric history
• Medication trials and current medications
• Psychotherapy or previous psychiatric diagnosis
• Pertinent substance use, family psychiatric/substance use, social, and medical history
• Allergies
• ROS
• Read rating descriptions to see the grading standards!

In the Objective section, provide:
• Physical exam documentation of systems pertinent to the chief complaint, HPI, and history
• Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses.
• Read rating descriptions to see the grading standards!

In the Assessment section, provide:
• Results of the mental status examination, presented in paragraph form.
• At least three differentials with supporting evidence. List them from top priority to least priority. Compare the DSM-5 diagnostic criteria for each differential diagnosis and explain what DSM-5 criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
• Read rating descriptions to see the grading standards!
Reflect on this case. Include what you learned and what you might do differently. Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).
(The comprehensive evaluation is typically the initial new patient evaluation. You will practice writing this type of note in this course. You will be ruling out other mental illnesses so often you will write up what symptoms are present and what symptoms are not present from illnesses to demonstrate you have indeed assessed for all illnesses which could be impacting your patient. For example, anxiety symptoms, depressive symptoms, bipolar symptoms, psychosis symptoms, substance use, etc.)
EXEMPLAR BEGINS HERE
CC (chief complaint): A brief statement identifying why the patient is here. This statement is verbatim of the patient’s own words about why they are presenting for assessment. For a patient with dementia or other cognitive deficits, this statement can be obtained from a family member.
HPI: Begin this section with patient’s initials, age, race, gender, purpose of evaluation, current medication, and referral reason. For example:
N.M. is a 34-year-old Asian male who presents for psychotherapeutic evaluation for anxiety. He is currently prescribed sertraline by (?) which he finds ineffective. His PCP referred him for evaluation and treatment.
Or
P.H. is a 16-year-old Hispanic female who presents for psychotherapeutic evaluation for concentration difficulty. She is not currently prescribed psychotropic medications. She is referred by her mental health provider for evaluation and treatment.
Then, this section continues with the symptom analysis for your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis.
Paint a picture of what is wrong with the patient. This section contains the symptoms that is bringing the patient into your office. The symptoms onset, the duration, the frequency, the severity, and the impact. Your description here will guide your differential diagnoses. You are seeking symptoms that may align with many DSM-5 diagnoses, narrowing to what aligns with diagnostic criteria for mental health and substance use disorders. You will complete a psychiatric ROS to rule out other psychiatric illnesses.
Past Psychiatric History: This section documents the patient’s past treatments. Use the mnemonic Go Cha MP.
General Statement: Typically, this is a statement of the patients first treatment experience. For example: The patient entered treatment at the age of 10 with counseling for depression during her parents’ divorce. OR The patient entered treatment for detox at age 26 after abusing alcohol since age 13.
Caregivers are listed if applicable.
Hospitalizations: How many hospitalizations? When and where was last hospitalization? How many detox? How many residential treatments? When and where was last detox/residential treatment? Any history of suicidal or homicidal behaviors? Any history of self-harm behaviors?
Medication trials: What are the previous psychotropic medications the patient has tried and what was their reaction? Effective, Not Effective, Adverse Reaction? Some examples: Haloperidol (dystonic reaction), risperidone (hyperprolactinemia), olanzapine (effective, insurance wouldn’t pay for it)
Psychotherapy or Previous Psychiatric Diagnosis: This section can be completed one of two ways depending on what you want to capture to support the evaluation. First, does the patient know what type? Did they find psychotherapy helpful or not? Why? Second, what are the previous diagnosis for the client noted from previous treatments and other providers. (Or, you could document both.)
Substance Use History: This section contains any history or current use of caffeine, nicotine, illicit substance (including marijuana), and alcohol. Include the daily amount of use and last known use. Include type of use such as inhales, snorts, IV, etc. Include any histories of withdrawal complications from tremors, Delirium Tremens, or seizures.
Family Psychiatric/Substance Use History: This section contains any family history of psychiatric illness, substance use illnesses, and family suicides. You may choose to use a genogram to depict this information (be sure to include a reader’s key to your genogram) or write up in narrative form.
Psychosocial History: This section may be lengthy if completing an evaluation for psychotherapy or shorter if completing an evaluation for psychopharmacology. However, at a minimum, please include:
• Where patient was born, who raised the patient
• Number of brothers/sisters (what order is the patient within siblings)
• Who the patient currently lives with in a home? Are they single, married, divorced, widowed? How many children?
• Educational Level
• Hobbies
• Work History: currently working/profession, disabled, unemployed, retired?
• Legal history: past hx, any current issues?
• Trauma history: Any childhood or adult history of trauma?
• Violence Hx: Concern or issues about safety (personal, home, community, sexual (current & historical)

Medical History: This section contains any illnesses, surgeries, include any hx of seizures, head injuries.

Current Medications: Include dosage, frequency, length of time used, and reason for use. Also include OTC or homeopathic products.
Allergies: Include medication, food, and environmental allergies separately. Provide a description of what the allergy is (e.g., angioedema, anaphylaxis). This will help determine a true reaction vs. intolerance.
Reproductive Hx: Menstrual history (date of LMP), Pregnant (yes or no), Nursing/lactating (yes or no), contraceptive use (method used), types of intercourse: oral, anal, vaginal, other, any sexual concerns
Diagnostic results: Include any labs, X-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines).
Assessment
Mental Status Examination: For the purposes of your courses, this section must be presented in paragraph form and not use of a checklist! This section you will describe the patient’s appearance, attitude, behavior, mood and affect, speech, thought processes, thought content, perceptions (hallucinations, pseudo hallucinations, illusions, etc.), cognition, insight, judgment, and SI/HI. See an example below. You will modify to include the specifics for your patient on the above elements—DO NOT just copy the example. You may use a preceptor’s way of organizing the information if the MSE is in paragraph form.
He is an 8 yo African American male who looks his stated age. He is cooperative with examiner. He is neatly groomed and clean, dressed appropriately. There is no evidence of any abnormal motor activity. His speech is clear, coherent, normal in volume and tone. His thought process is goal directed and logical. There is no evidence of looseness of association or flight of ideas. His mood is euthymic, and his affect appropriate to his mood. He was smiling at times in an appropriate manner. He denies any auditory or visual hallucinations. There is no evidence of any delusional thinking. He denies any current suicidal or homicidal ideation. Cognitively, he is alert and oriented. His recent and remote memory is intact. His concentration is good. His insight is good.
Differential Diagnoses: You must have at least three differentials with supporting evidence. Explain what rules each differential in or out and justify your primary diagnosis selection. Include pertinent positives and pertinent negatives for the specific patient case.

Also included in this section is the reflection. Reflect on this case and discuss whether or not you agree with your preceptor’s assessment and diagnostic impression of the patient and why or why not. What did you learn from this case? What would you do differently?
Also include in your reflection a discussion related to legal/ethical considerations (demonstrating critical thinking beyond confidentiality and consent for treatment!), social determinates of health, health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).

Case Formulation and Treatment Plan.
Includes documentation of diagnostic studies that will be obtained, referrals to other health care providers, therapeutic interventions with psychotherapy, education, disposition of the patient, and any planned follow-up visits. Each diagnosis or condition documented in the assessment should be addressed in the plan. The details of the plan should follow an orderly manner. *see an example below—you will modify to your practice so there may be information excluded/included—what does your preceptor document?
Example:
Initiation of (what form/type) of individual, group, or family psychotherapy and frequency.
Documentation of any resources you provide for patient education or coping/relaxation skills, homework for next appointment.
Client has emergency numbers: Emergency Services 911, the Client’s Crisis Line 1-800-_______. Client instructed to go to nearest ER or call 911 if they become actively suicidal and/or homicidal. (only if you or preceptor provided them)

Reviewed hospital records/therapist records for collaborative information; Reviewed PCP report (only if actually available)

Time allowed for questions and answers provided. Provided supportive listening. Client appeared to understand discussion. Client is amenable with this plan and agrees to follow treatment regimen as discussed. (This relates to informed consent; you will need to assess their understanding and agreement.)

Follow up with PCP as needed and/or for:

Write out what psychotherapy testing or screening ordered/conducted, rationale for ordering

Any other community or provider referrals

Return to clinic:

Continued treatment is medically necessary to address chronic symptoms, improve functioning, and prevent the need for a higher level of care OR if one-time evaluation, say so and any other follow up plans.
References (move to begin on next page)
You are required to include at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines which relate to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting.

In the Subjective section of the psychiatric evaluation, the chief complaint is “I’m here for a follow-up.” The history of present illness (HPI) includes the patient reporting increased anxiety due to the recent loss of their father and the urge to drink again. The patient’s past psychiatric history includes a previous diagnosis of unspecified depressive disorder and alcohol/ecstasy use. The patient is currently taking Remeron 30mg PO QHS, Celexa 20 mg PO Q AM, and Zoloft 25 mg PO Q daily, and reports that these medications have been effective. The patient is seeking therapy/counseling due to the recent loss in the family. The patient denies any past inpatient or outpatient hospitalization, and any past history of family psychiatric illnesses or substance abuse. In terms of substance use, the patient reports a history of alcohol and ecstasy use. The patient is single and in a relationship, living with a friend and renting. The patient denies any allergies and reports no significant issues with sleep, appetite, or energy levels.
In the Objective section, the physical examination is not specified in the case scenario. The diagnostic results are not specified in the case scenario.
In the Assessment section, the results of the mental status examination show that the patient presents with euthymic mood and affects, fair insight and judgment, and no display of psychosis. The thought process is clear and coherent, and the content does not reveal delusions, paranoia, or suicidal ideations. The patient reports increased anxiety due to the recent loss of their father. The patient’s primary diagnosis is unspecified depressive disorder, substance abuse disorder, alcohol abuse, and anxiety disorder. The patient’s treatment plan is to continue with the current medications and refer the patient for therapy.
In reflection, this case highlights the importance of considering the impact of a significant loss, such as the death of a loved one, on a patient’s mental health and the potential for increased substance use as a coping mechanism. It is important to address both the patient’s mental health and substance use in treatment, and refer the patient for therapy to address the loss and coping mechanisms. Additionally, it is important to consider the patient’s age, ethnic group, and socioeconomic status in treatment, as these factors may impact their access to and engagement in mental health services. It is also important to consider the legal and ethical considerations such as confidentiality and informed consent in treatment.

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