Comprehensive Psychiatric Evaluation Note-Nursing Paper Examples

Subjective:

CC: “My mom thinks I am lazy, but I keep forgetting about the tasks she wants me to do. At school, I cannot remember what I have been taught after the lesson.” (Psychiatric Evaluation Note).

HPI: DT is an 11-year-old African American female present for psychiatric assessment in the company of her mother. The mother is concerned that her daughter is increasingly becoming lazy and disobedient as she cannot complete tasks assigned to her at home and school. I find school difficult, and I don’t like school anymore.” The client has not gone to school since last week as she finds studies challenging. She cannot pass her math tests and feels like a “dummy.” I am worthless and useless to my mom, siblings, and peers at school.

” She believes she can never make it academically as she has tried to study hard but keeps failing over the years. She has trouble paying attention in class and sleeps through most lessons. “I forget immediately after I leave the lecture ends.” Any thought or discussion regarding school makes her anxious and angry. The mother reported that she cut her legs the day before the psychiatric appointment and feels like she is not worth living. The client reported hearing “things” telling her to end it all as she cannot achieve academically. She is already behind by 2 years. The mother reported finding the client talking to herself on many occasions (Psychiatric Evaluation Note).

Past Psychiatric History:

General Statement: The client entered treatment aged 3 years for speech development. Caregivers: The client is taken care of by the mother.

Hospitalizations: No previous hospitalization. Detox taken two months ago. The client reports suicidal thoughts. She has a history of self-harm.

Medication trials: No significant medication trials.

Psychotherapy or Previous Psychiatric Diagnosis: Diagnosed with language development disorder at age 3 and underwent speech therapy successfully.

Substance Use History: She reported taking alcohol but is in control of her drinking.She denies caffeine, nicotine, and illicit substance abuse.

Family Psychiatric/Substance Use History:  Denies family history of psychiatric illness or substance abuse.

Social History:  The client was born and raised in Minneapolis, Minnesota. Lives with her mom.The mother has never been married. She has a younger brother. Consequently, she is in grade 4 and likes biking and adventure. She is unemployed and has no legal issues or safety concerns at home (Psychiatric Evaluation Note).

Medical History: (Psychiatric Evaluation Note)

Current Medications: No current medications.

Allergies:NKFDA

Reproductive Hx:Not sexually active. Regular periods.

ROS:

GENERAL: No weight loss, fever, chills, weakness, or fatigue.

HEENT: Eyes: No visual loss. Ears, Nose, Throat: No hearing loss, nasal congestion, or sore throat.

SKIN: No rash or itching.

CARDIOVASCULAR: No chest pain/chest pressure/chest discomfort. No palpitations or edema.

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

GASTROINTESTINAL: No nausea, vomiting, or diarrhea. No abdominal pain or blood.

GENITOURINARY: No burning urination, hesitancy, or urgency.  

NEUROLOGICAL: No headache, numbness, or tingling in the extremities.

MUSCULOSKELETAL: No back pain, muscle stiffness, or joint pain.

HEMATOLOGIC: No anemia, bleeding, or bruising.

LYMPHATICS: No enlarged nodes. No history of splenectomy.

ENDOCRINOLOGIC: No sweat, cold, or heat intolerance. No polyuria or polydipsia.

Physical Exam: NA

Diagnostic results: The Vanderbilt Assessment Scale would effectively provide crucial information to ascertain ADHD diagnosis and rule out other diagnoses. Besides, the scale can assess anxiety and depression (Bussing et al., 2020). Furthermore, the scale is effective for children between 6 and 12 years and has a high sensitivity to ADHD and specificity predicting ADHD (Psychiatric Evaluation Note).

Assessment

Mental Health Examination: She is poorly kept and appears disoriented. She is calm, withdrawn, and appears to be in significant distress. Furthermore, she reports feeling down, and the effect is congruent with her mood. She fidgets during the exam and does not seem to pay attention to the discussion. Consequently, the mother has to remind her to respond to questions (Psychiatric Evaluation Note).

Subsequently, The client has a flight of ideas, and the thought-form and content are scattered. Besides, she reports auditory hallucinations. Furthermore, her cognition and memory are below average, and she struggles with abstract thought. In addition, her judgment and insight are poor. On the other hand, she denies an active sense of suicide or homicide ideation. The client has a high risk of half harm but a low risk to others (Psychiatric Evaluation Note).

Differential Diagnosis

Moderate Attention-Deficit/Hyperactivity Disorder, 314.00 (F90.0), predominantly inattentive presentation. The diagnostic criteria for ADHD, inattentive type, include inattention that has been persistent for at least six months and inconsistent with developmental level, leading to impaired social, occupational, and academic activities. Inattention is characterized by symptoms such as the inability to pay attention to details or making careless mistakes, difficulty sustaining attention, ease of distraction, inability to follow instructions/finish school work, difficulty with the organization of tasks/activities, reluctance to engaging in activities that require sustained attention, losing things, ease of distraction, and forgetfulness (American Psychiatric Association [APA], 2019)(Psychiatric Evaluation Note).

Moderate Major Depressive Disorder, 296.22 (F32.1), with anxious distress. The diagnostic criteria for MDD include depressed mood or diminished pleasure in activities daily and for most of the day. Individuals show symptoms such as weight loss/gain, fatigue, psychomotor agitation, worthlessness, insomnia or hypersomnia, recurrent thoughts of death, and inability to concentrate. This is a secondary diagnosis (Psychiatric Evaluation Note).

Moderate Bipolar II Disorder, 296.89 (F31.81), with seasonal pattern. The diagnostic criteria for BD-II include current or past hypomanic episodes and current or past major depressive episodes. Hypomanic episodes are characterized by elevated mood/irritability with increased energy noticeable by others for at least four days (APA, 2019). Consequently, Symptoms include unreasonably high self-esteem, hypersomnia, talkativeness, flight of ideas, distractibility, psychomotor agitation, and involvement in harmful activities (APA, 2019).

Moreover, Depressive episodes are characterized by depressed mood or diminished pleasure in daily activities and for most of the day. Individuals show symptoms such as weight loss/gain, fatigue, psychomotor agitation, worthlessness, insomnia or hypersomnia, recurrent thoughts of death, and inability to concentrate. Hence, This is a secondary diagnosis (Psychiatric Evaluation Note).

Reflection

Although the client presents symptoms that suggest other diagnoses, including MDD and BD-II, ADHD inattentive type is the primary diagnosis. Inattentive symptoms are mostly present before age twelve in more than one setting. In this case, the client’s inattentive symptoms are shown in school and at home. Furthermore, These symptoms affect social and academic function. Hence, justifies why the client fails at school and the inability to complete house chores (Psychiatric Evaluation Note).

The other prognoses, MDD and BD-II are ruled out considering the client’s symptoms are better explained by ADHD. ADHD and MDD are associated with forgetfulness, mood problems, and inattention (Boland & Verduin, 2021). However, the moods associated with ADHD are transient and triggered by a setback, while those associated with MDD are chronic and pervasive. Therefore, ADHD inattentive type is the primary diagnosis (Psychiatric Evaluation Note).  

ADHD affects academic performance and consequent achievement (Boland & Verduin, 2021). Moreover, ADHD can contribute to obsessive-compulsive and antisocial personality disorders, leading to substance use disorders. Furthermore, Other outcomes include engagement in violent behavior, accidents, and dangerous activities (Boland & Verduin, 2021) (Psychiatric Evaluation Note).

Consequently, obesity, laziness or irresponsibility, discord in families, disrupted peer interactions, and bullying are common outcomes of ADHD in an individual. Risk and prognostic factors for ADHD include low birth weight, smoking during pregnancy, genetic elements, adverse childhood, and utero alcohol exposure.

The overarching ethical consideration is beneficence, i.e., to promote well-being, and nonmaleficence, i.e., avoid harm (Jain et al., 2017). Consequently, a PMHNP should ensure that they provide interventions to protect against exacerbation of symptoms and consequent adverse outcomes. On the other hand, the PMHNP should avoid causing harm by prescribing appropriate medication and therapy (Psychiatric Evaluation Note).

Knowing the potential adverse outcome of pharmacological interventions, the PMHNP should uphold competency in pharmacology and pharmacokinetics of mental health drugs to avoid adverse outcomes. The other significant ethical concern is informed consent, i.e., the client’s rights to information about their health and constitution to treatment.

References

American Psychiatric Association (APA). (2019). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Publishing

Jain, S., Kuppili, P. P., Pattanayak, R. D., & Sagar, R. (2017). Ethics in psychiatric research: Issues and recommendations. Indian Journal of Psychological Medicine, 39(5), 558-565. https://doi.org/10.4103%2FIJPSYM.IJPSYM_131_17

Boland, R., & Verduin, M. (2021). Kaplan & Sadock’s Concise Textbook of Clinical Psychiatry. Lippincott Williams & Wilkins.

Bussing, R., Gagnon, J. C., Garvan, C. W., Ribuffo-Duggan, C., & Houchins, D. (2020). Psychometric properties of the Vanderbilt ADHD diagnostic rating scale completed by juvenile corrections staff. Journal of Attention Disorders, 24(11), 1521-1529. https://doi.org/10.1177/1087054717690811

Wheeler, K. (2020). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice. Springer Publishing Company.