Comprehensive Psychiatric Evaluation

Comprehensive Psychiatric Evaluation Note Template-A Nursing Paper Example

CC (chief complaint): “Yeah, I’d like to learn to lead my life alone and depend on the kids a lot because in our customs, when the parents get old and especially when they are in my situation, they can’t walk or take care of theirself, the kids are always there for parents, but over here no, they have their own life.”(Comprehensive Psychiatric Evaluation Note Template-A Nursing Paper Example)

HPI: Ms. P, aged 40, and Ms. S, aged 23, are mother and daughter, respectively. The two are Iranian immigrants in for a consultation as a family. The therapist and the reflecting team are in to reflect on the family situation. Ms. is a single mother of five children, four daughters, and a son. The family is dealing with several forms of trauma, a history of domestic violence, child sexual abuse, and the effects of immigration on culture. Ms. P complains that her children are out of control. She immigrated to the USA accompanied by her four children ten years ago. One of her children remained behind due to visa issues but joined them two years later. The daughter who was left behind was sexually abused by the father and now blames Ms. P for it. Ms. P is currently incapacitated following failed surgeries and is in excruciating discomfort. Her status is causing anxiety and strain in the family. Ms. P is equally worried, helpless, and hopeless that she can no longer control her children.(Comprehensive Psychiatric Evaluation Note Template-A Nursing Paper Example)

Conversely, Ms. P is attempting to keep them. She argues that whom she argues the children do not enough for her. She anticipates her children paying her visits and spending most of their time with her. Ms. S is concerned that the mother is planning her life, deciding her happiness and friends and oblivious to the other things she has to do. Ms. P reports not getting along with the older son. The children want her to be self-sufficient, remain positive and independent, and avoid expecting much from them. Ms. S laments that their mother is not concerned with their growth and ability to assume roles, suffocating them with her thoughts. (Comprehensive Psychiatric Evaluation Note Template-A Nursing Paper Example)

Psychotherapy Genogram

21

Father

Brother

Brother

Shireen

Sharleen

Sheela

Neglect

Distant

23

24

15

18

Ms.P

Key

Estranged

Physical violence/Sexual assault

Separated

Past Psychiatric History: No history of diagnosed mental health issues despite a history of sexual and physical abuse. Ms. P reports being depressed.(Comprehensive Psychiatric Evaluation Note Template-A Nursing Paper Example)

• General Statement: The clients entered treatment about 1.5 years ago for family counseling.
• Caregivers (if applicable): NA.

• Hospitalizations: No history of mental health hospitalization.
• Medication trials: No medication trials were reported.
• Psychotherapy or Previous Psychiatric Diagnosis: No previous mental health diagnosis. The clients have been in therapy for 1.5 years.

Substance Current Use and History: No substance use history was reported (alcohol, nicotine, or cocaine).

Family Psychiatric/Substance Use History: No history of mental health illnesses or substance abuse.

Psychosocial History: The client was born and raised in Ira, Married off at age 14. She has five children, three daughters, and two sons.The client is currently separated and lives with two sons. The client is unemployed and disabled. No legal issues were reported. She is currently disabled after two failed surgeries. She is unemployed with no past or current legal issues. (Comprehensive Psychiatric Evaluation Note Template-A Nursing Paper Example)

Medical History: No medical history was recorded.The client had unsuccessful foot surgeries. Current Medications: None reported.(Comprehensive Psychiatric Evaluation Note Template-A Nursing Paper Example)

• Allergies:NKFDA
• Reproductive Hx:G5P5. Separates.

ROS:

• GENERAL: There is no report of weight loss, fever, fatigue, or weakness.
• HEENT: No visual changes. No loss of hearing or nasal congestion. No sore throat or difficulty swallowing.  (Comprehensive Psychiatric Evaluation Note Template-A Nursing Paper Example)
• SKIN: Normal skin turgor.
• CARDIOVASCULAR: No chest palpitations or pain.
• RESPIRATORY: Normal breath. No cough or sputum.
• GASTROINTESTINAL: No abdominal pain, constipation, or diarrhea. No anorexia, nausea, or vomiting.
• GENITOURINARY: Burning on urination, hesitancy, urgency, or pain
• NEUROLOGICAL: No tingling in the extremities, numbness, headache, or syncope.
• MUSCULOSKELETAL: No muscle pain or stiffness. No joint or back pain.
• HEMATOLOGIC: No bleeding, bruising, or anemia.(Comprehensive Psychiatric Evaluation Note Template-A Nursing Paper Example)
• LYMPHATICS: No enlarged nodes or splenectomy.
• ENDOCRINOLOGIC: No polyuria, polydipsia, or polyphagia.

Physical exam: Completed by PCP.

Vital Signs: T- 98.5 R 16 107/74 Ht 5’6 Wt 120lbs

Diagnostic results: The Beck Depression Inventory (BDI) screens the degree of depression and establishes behavioral manifestations (Boland & Verduin, 2021).(Comprehensive Psychiatric Evaluation Note Template-A Nursing Paper Example)

Assessment

Mental Status Examination: Th clients are alert and oriented in all spheres. The cleits are cooperative and conversant. The clients are worried, and the mood is congruent with affect. The client maintains appropriate eye contact. Ms. P’s thought form and content are resigned and conflicted. The client’s speech is clear and coherent. No flight of ideas was noted during the consultation. No suicide or homicide ideation was noted. No visual or auditory hallucinations or delusions were noted. The clients’ memory is recent. Judgment and insight are normal. No difficulty with concentration or attention was noted during the exam.(Comprehensive Psychiatric Evaluation Note Template-A Nursing Paper Example)

Her memory, insight, and judgment are intact. The patient did not show difficulty with concertation.

Differential Diagnoses:

1. 309.28 (F43.23), Adjustment Disorder: Adjustment disorder is characterized by behavioral and emotional responses to a perceived stressor (American Psychiatric Association, 2019). Such responses are often disproportionate based on cultural and contextual circumstances. The responses are not associated with normal bereavement and affect significant areas of functioning. (Comprehensive Psychiatric Evaluation Note Template-A Nursing Paper Example)
2. 309.21 (F93.0), Separation Anxiety Disorder (SAD): Separation anxiety disorder is characterized by disproportionate and excessive anxiety or fear of separating from attached figures (APA, 2019). Individuals experience persistent anticipation of separation, excessive worry and refusal to let go, nightmares, physical symptoms, and fear of being alone. (Comprehensive Psychiatric Evaluation Note Template-A Nursing Paper Example)
3. 309.81 (F43.10), Posttraumatic Stress Disorder: Posttraumatic stress disorder ischaracterized by actual or threatened exposure to a traumatic events (APA, 2019). Such exposure could be through direct experience, witnessing, or learning about them. Individuals experience intrusive thoughts associated with the events in the form of distressing memories, dreams, flashbacks, or intense psychological responses. Moreover, individuals experience persistent avoidance and altered cognition characterized by the inability to recall aspects of the event, negative beliefs, doctored cognition, negative emotional state, detachment, and diminished interest in activities. Lastly, individuals experience altered reactivity to traumatic events, such as irritability, recklessness, startle response, inability to concentrate, sleep disturbances, and hypervigilance.(Comprehensive Psychiatric Evaluation Note Template-A Nursing Paper Example)

Case Formulation and Treatment Plan:

1. Pharmacotherapy: Start Sertraline 25 mg PO qDay, adjusted as needed. Sertraline effectively manages depressive symptoms (Singh & Saidabad, 2019).  (Comprehensive Psychiatric Evaluation Note Template-A Nursing Paper Example)
2. Psychotherapy: Start 12 sessions of family cognitive behavioral therapy. Cognitive behavioral therapy helps patients gain coping skills through social problem-solving and cognitive restructuring (Boland & Verduin, 2021).(Comprehensive Psychiatric Evaluation Note Template-A Nursing Paper Example)
3. Education: Discuss with the clients the importance of self-care and effective ways to solve family feuds. Discuss with Ms. P the different parenting styles in the family. Discuss with the clients the importance of effective communication skills in the family. Provide reading material and resources for family unity.
4. CBT would provide the patient with age-appropriate coping skills, including impulse, communication, anger management, stress, and problem-solving skills (Leterme et al., 2020).(Comprehensive Psychiatric Evaluation Note Template-A Nursing Paper Example)

Reflections:

Adjustment disorder with depressed mood and anxiety is the primary diagnosis. Ms. P is concerned that her children are no longer under her control, and she is worried that they don’t listen to her or visit her as often as the culture demands of children when their parents are older. The client presents symptoms suggesting separation anxiety disorder, fear of letting go, excessive worry, and anticipation of separation (Masterswork Productions, 2003). The client’s worry about remaining alone is a significant concern and source of anxiety for Ms. P. She wants to spend more time with them as she is not yet done with them. Moreover, the client presents PTSD symptoms such as a history of sexual and physical abuse leading to a startled response to perceive though of her children interacting with men (Masterswork Productions, 2003). However, the diagnosis is refuted, considering no significant aspects of PTSD, such as distressing memories, dreams, or flashbacks.(Comprehensive Psychiatric Evaluation Note Template-A Nursing Paper Example)

Informed consent and confidentiality are crucial ethical and legal concerns in this case. The practitioner should provide informed consent considering the presence of the reflecting team and consulting counselor besides the client, the family, and the therapist. Moreover, the client should be informed of their rights to refute the therapy, the risks, and the importance of the therapy. Informed consent and confidentiality are crucial in establishing rapport with the clients and maintaining an appropriate therapeutic alliance. Furthermore, the practitioner should consider the cultural impact on health-seeking behavior. In this case, other family members are not in, probably due to their view of psychotherapy as shaped by their culture. The cultural context of the case should be considered when making clinical decisions to determine whether they are maladaptive or excessive.(Comprehensive Psychiatric Evaluation Note Template-A Nursing Paper Example)

References

Masterswork Productions. (2003). Mother and daughter: A cultural taleLinks to an external site. [Video/DVD]. https://go.openathens.net/redirector/waldenu.edu?url=https://video.alexanderstreet.com/watch/mother-and-daughter-a-cultural-tale

Singh, H. K., & Saadabadi, A. (2019). Sertraline. Available at: https://www.ncbi.nlm.nih.gov/books/NBK547689/ (Accessed 11 March 2023)

American Psychiatric Association. (2019). Diagnostic and statistical manual of mental disorders (7^th ed.). American Psychiatric Publishing, Inc.   

Ford, J., Thomas, F., Byng, R., & McCabe, R. (2020). Use of the Patient Health Questionnaire (PHQ-9) in Practice: Interactions between patients and physicians. Qualitative Health Research, 30(13), 2146-2159. https://doi.org/10.1177%2F1049732320924625

Lakshmi, G. P. (2017). Effectiveness of an Integrative Approach on Adjustment Disorder. Psychology and Behavioral Science International Journal, 5(4), 1-7. Retrieved 9 September, from: https://juniperpublishers.com/pbsij/pdf/PBSIJ.MS.ID.555668.pdf

Leterme, A. C., Behal, H., Demarty, A. L., Barasino, O., Rougegrez, L., Labreuche, J., … & Servant, D. (2020). A blended cognitive behavioral intervention for patients with adjustment disorder with anxiety: a randomized controlled trial. Internet Interventions, 21, 100329. https://doi.org/10.1016%2Fj.invent.2020.100329

Mahase, E. (2019). Sertraline is better at reducing anxiety than depressive symptoms. BMJ: British Medical Journal (Online), 366. https://doi.org/10.1136/bmj.l5655

Sun, Y., Fu, Z., Bo, Q., Mao, Z., Ma, X., & Wang, C. (2020). The reliability and validity of PHQ-9 in patients with major depressive disorder in a psychiatric hospital. BMC Psychiatry, 20(1), 1-7. https://doi.org/10.1186%2Fs12888-020-02885-6

Nichols, M., & Davis, S. D. (2020). The essentials of family therapy (7th ed.). Pearson.

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