Comprehensive psychiatric evaluations are a way to reflect on your practicum experiences and connect the experiences to the learning you gain from your weekly Learning Resources. Comprehensive 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 5 weeks, using the Comprehensive Psychiatric Evaluation Template provided. You will then use this note to develop and record a case presentation for this patient.
Assignment:
- Select a patient that you examined during the last 5 weeks. Review prior resources on the disorder this patient has. (Note to Writer: You may use below “Patient” information and create addtl’ information as needed to complete assignment to the fullest.)
- Conduct a Comprehensive Psychiatric Evaluation on this patient using the template provided. There is also a completed exemplar document so that you can see an example of the types of information a completed evaluation document should contain.
- 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.
- Include at least five (5) scholarly resources to support your assessment and diagnostic reasoning.
Patient:
32yo Hispanic Male
Dx: – Major Depressive Disorder with psychotic features – Generalized Anxiety d/o – Alcohol Induced insomnia
Medication: – Trazadone 50mg HS PRN – Hydroxyzine 50mg PRN
First time patient intake joint care with provider. Patient states he hasn’t had his full-time job as a truck driver in over one year, states he hurt his hand, so only does side jobs ‘here and there’ for income. Has high levels of anxiety being around people and cannot come out of his house without feelings of anxiety. Endorses a history of alcohol and cocaine use, denies any recent use of cocaine and that he hasn’t had a drink in about 10-days. Sleeps only 4-5hrs a night. Endorses past feelings of suicide, however didn’t attempt due to his wife and son. Denies any past history of sexual or physical abuse. Denies family history of mental illness.
Plan: Continue to seek out therapy and stay consistent with visits Begin working out, slowly at first, such as short walks. Try to find a more stable job, full-time to help reduce stressors Begin healthier sleep hygiene habits such as avoiding alcohol and any caffeinated drinks, and going to bed between 9pm and 10pm, avoiding using his cellphone like being on social media right before bed.
Follow up with provider immediately if symptoms worsen, otherwise, follow up in 2-days.
Resources to consider:
- American Psychiatric Association. (2022). Disruptive, impulse-control, and conduct disordersLinks to an external site.. In Diagnostic and statistical manual of mental disorders (5th ed., text rev.).
- American Psychiatric Association. (2022). Dissociative disordersLinks to an external site.. Diagnostic and statistical manual of mental disorders (5th ed., text rev.).
- American Psychiatric Association. (2022). Somatic symptom and related disordersLinks to an external site.. In Diagnostic and statistical manual of mental disorders (5th ed., text rev.).
- Boland, R. Verdiun, M. L. & Ruiz, P. (2022). Kaplan & Sadock’s synopsis of psychiatry (12th ed.). Wolters Kluwer.
NOTE: Please use Resources/References not older than 5-years. (Late 2018/2019 – 2023)
Rubric
