NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template Example

NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template Example

By Day 7 of Week 3

Complete and submit your Comprehensive Psychiatric Evaluation, including your differential diagnosis and the critical-thinking process used to formulate the primary diagnosis. Incorporate the following into your responses within the template:

Subjective:

Chief Complaint (CC): Occasionally, I find it difficult to hold my own child. She’s crying, and I struggle to touch her. When I give her milk, it disgusts me. I can’t stop crying all the time, and I tend to yell a lot.

History of Present Illness (HPI): Mrs. Tilman, a 32-year-old woman, arrives for a psychiatric assessment with her husband, Rick. She is a new mother to a two-month-old baby girl named Jessica. Her husband is concerned about her behavior since the birth of their baby. Mrs. Tilman reports that she was in good health until recently after giving birth. She has been experiencing sleep difficulties due to the baby’s frequent night-time crying. She has also gained weight during pregnancy and expresses a desire to lose it. She feels distressed about her physical appearance, citing bloating, facial lines, and bags under her eyes. Despite this, her appetite is poor, and she desires to exercise but finds it challenging due to her responsibilities at home with the baby. She feels trapped at home and has been crying excessively. Her relationship with her husband has deteriorated, leading to a lack of sexual desire and frequent rejection of his advances. Mrs. Tilman is currently a stay-at-home mother and has not been in contact with friends for some time. She previously worked as a research scientist and a substitute teacher in a secondary school for five years but resigned to care for the baby. She denies any alcohol or substance abuse but admits to having suicidal thoughts. She discloses a family history of suicide, specifically, her uncle, who was an opioid abuser and committed suicide with a gunshot wound. Her uncle had a history of hypertension and was prescribed labetalol 100 mg twice daily. However, she acknowledges missing some doses due to poor memory. Mrs. Tilman also reports an allergy to codeine.

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Past Psychiatric History:

General Statement: Family history of suicide

Caregivers (if applicable): Resides with her husband, no nanny

Hospitalizations: No previous hospitalizations on record

Medication trials: No reported history of medication trials

Psychotherapy or Previous Psychiatric Diagnosis: No reported history of psychotherapy or psychiatric diagnosis

Substance Current Use and History: Denies any substance or alcohol abuse

Family Psychiatric/Substance Use History: Family history includes an uncle who was an opioid abuser and died by suicide via gunshot wound

Psychosocial History:

Medical History: Labetalol 100 mg twice daily

Current Medications: Labetalol 100 mg twice daily

Allergies: Allergic to codeine

Reproductive History: First-time mother of a two-month-old baby girl, Jessica. Reports a lack of sexual motivation, with her husband having to initiate sexual activity.

Review of Systems (ROS):

GENERAL: Alert but distressed, weight gain, reduced appetite, and memory difficulties

HEENT: Denies headaches, head trauma, or injuries. No yellowing of the eyes, double or blurred vision, hearing problems, or use of hearing aids. No history of tonsillitis, nasal obstructions, nosebleeds, dental pain, sore throat, ulcerations, or dysphagia.

SKIN: No rash, lesions, itching, or abnormal sweating

CARDIOVASCULAR: No chest pain, congestion, pressure, or discomfort. Absence of palpitations, murmurs, or edema in the lower extremities

RESPIRATORY: No shortness of breath, wheezing, or cough. Absence of sputum

GASTROINTESTINAL: No nausea, vomiting, or loose stools

GENITOURINARY: No urinary frequency, dysuria, or urinary urgency

NEUROLOGICAL: No dizziness, paralysis, numbness, unconsciousness, or headaches

MUSCULOSKELETAL: No complaints of muscle or joint pain, stiffness, or joint pain

HEMATOLOGIC: No bruising, anemia, blood sepsis, bleeding, or hemophilia

LYMPHATICS: No signs of bruising or lymph node enlargement

ENDOCRINOLOGIC: Thyroid glands appear normal in size, shape, and structure

Objective:

Diagnostic Results: Mrs. Tilman’s physical measurements include a height of 5 feet 3 inches, a weight of 245 pounds, a temperature of 97.6°F, a pulse rate of 97 beats per minute, a respiratory rate of 22 breaths per minute, and a blood pressure of 149/90 mmHg.

Assessment:

Mental Status Examination:

Mrs. Tilman, a 32-year-old woman accompanied by her husband for a psychiatric evaluation, presents herself as her stated age but exhibits noticeable distress. She demonstrates full orientation across all four spheres (person, place, time, and situation). Her appearance is appropriate, clean, and well-groomed. Throughout the interview, she remains cooperative and maintains consistent eye contact. There are no observable abnormal motor behaviors. Mrs. Tilman’s speech, while clear, is at times incoherent due to her distress. Her affect is moody, with a somewhat restricted range, primarily characterized by sadness. She reports being upset with everything but does not exhibit acute psychosis or mood symptoms. There are no delusional thoughts, but she admits to experiencing suicidal thoughts. She has intrusive thoughts about harming her baby and husband but actively avoids situations that could lead to harm. Memory problems are noted, with Mrs. Tilman admitting to missing some doses of her hypertension (HTN) medication.

Differential Diagnoses:

1. Post-Partum Depression (PPD):

PPD, classified as a major depressive disorder by the DSM-5, is diagnosed during pregnancy or within the first four weeks postpartum. To meet the criteria for PPD, a patient must experience five or more of the following symptoms: feelings of depressed mood, reduced interest in almost everything, significant weight gain or loss, increased or decreased appetite, daily insomnia, persistent fatigue, feelings of worthlessness, recurrent thoughts of suicide, and reduced concentration (Dekel et al., 2020). In this case, Mrs. Tilman reports difficulty sleeping due to her baby’s frequent crying, postpartum weight gain, poor appetite, daily fatigue, feelings of looking and feeling terrible, a strained relationship with her husband, a lack of sexual desire, social withdrawal, frequent crying, and yelling. She also admits to having suicidal thoughts related to harming her baby and husband.

2. Adjustment Disorder with Depressed Mood:

This mental disorder is characterized by low mood, feelings of hopelessness, or tearfulness. Adjustment disorder typically occurs within three months of the onset of a stressor and is defined by the presence of emotional or behavioral symptoms in response to stressors. According to the DSM-5, these symptoms must cause significant distress and impair the individual’s functioning (Maercker & Lorenz, 2018). In Mrs. Tilman’s case, she is a new mother adjusting to postpartum changes in her body and the demands of motherhood. She describes her baby’s frequent night-time crying, dissatisfaction with her physical appearance, lack of support, loss of interest in her previous job, and social isolation as stressors contributing to her distress.

3. Acute Stress Disorder (ASD):

ASD is triggered by a traumatic event and typically emerges within the first month after the event. The disorder is characterized by intense anxiety, psychological shock, and subsequent symptoms. Individuals with a history of trauma, prior PTSD, or pre-existing mental health conditions are at higher risk of developing ASD in response to traumatic events (Bryant, 2018). While Mrs. Tilman exhibits some symptoms consistent with ASD, such as difficulty concentrating, reduced emotional responsiveness, poor memory, and a sense of detachment, she does not have a history of severely traumatic events (NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template Example).

Reflections:

A comprehensive assessment of mental disorders is considered the standard format for evaluating mental health, substance abuse, and individual needs. This approach provides a summary of the client’s needs, guiding diagnosis and the formulation of individualized care plans. Gathering both subjective and objective data is crucial to delivering person-centered care. Individualized care in mental health promotes dignity, respect, independence, and fulfillment in clients’ lives while also enhancing job satisfaction and reducing stress among professionals. Cultural competence is essential to meet individual client needs, and confidentiality must be ensured to encourage clients to share their concerns (Coyne et al., 2018).

References:

Bryant, R. A. (2018). The current evidence for acute stress disorder. Current Psychiatry Reports, 20(12), 1-8.

Coyne, I., Holmström, I., & Söderbäck, M. (2018). Centeredness in healthcare: a concept synthesis of family-centered care, person-centered care, and child-centered care. Journal of Pediatric Nursing, 42, 45-56.

Dekel, S., Ein-Dor, T., Dishy, G. A., & Mayopoulos, P. A. (2020). Beyond postpartum depression: posttraumatic stress-depressive response following childbirth. Archives of Women’s Mental Health, 23(4), 557-564.

Maercker, A., & Lorenz, L. (2018). Adjustment disorder diagnosis: Improving clinical utility. The World Journal of Biological Psychiatry, 19(Sup1), S3-S13.