NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template Sample 

NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template Sample 
Order: NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template Sample 

For this Assignment, you will document information about a patient that you 
examined during the last 3 weeks, using the Comprehensive Psychiatric Evaluation 
Template provided. You will then use this note to develop and record a case 
presentation for this patient. Be sure to incorporate any feedback you received on 
your Week 3 and Week 6 case presentations into this final presentation for the 
course.
To Prepare
• Review this week's Learning Resources and consider the insights they provide. Also 
review the Kaltura Media Uploader resource in the left-hand navigation of the 
classroom for help creating your self-recorded Kaltura video.
• Select a patient that you examined during the last 3 weeks who presented with a 
disorder for which you have not already conducted an evaluation in Weeks 3 or 6. 
(For instance, if you selected a patient with OCD in Week 6, you must choose a 
patient with another type of disorder for this week.) Conduct a Comprehensive 
Psychiatric Evaluation on this patient using the template provided in the Learning 
Resources. There is also a completed exemplar document in the Learning Resources 
so that you can see an example of the types of information a completed evaluation 
document should contain. All psychiatric evaluations must be signed, and each page 
must be initialed by your Preceptor. When you submit your document, you should 
include the complete Comprehensive Psychiatric Evaluation as a Word document, as 
well as a PDF/images of each page that is initialed and signed by your Preceptor. 
You must submit your document using SafeAssign. Please Note: Electronic 
signatures are not accepted. If both files are not received by the due date, Faculty 
will deduct points per the Walden Late Policies.
• Then, based on your evaluation of this patient, develop a video case presentation 
that includes 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.
• Ensure that you have the appropriate lighting and equipment to record the 
presentation
Assignment
Record yourself presenting the complex case for your clinical patient.
Do not sit and read your written evaluation! The video portion of the assignment is a 
simulation to demonstrate your ability to succinctly and effectively present a complex case 
to a colleague for a case consultation. The written portion of this assignment is a simulation 
for you to demonstrate to the faculty your ability to document the complex case as you 
would in an electronic medical record. The written portion of the assignment will be used 
as a guide for faculty to review your video to determine if you are omitting pertinent 
information or including non-essential information during your case staffing consultation 
video.
In your presentation:
• Dress professionally and present yourself in a professional manner.
• Display your photo ID at the start of the video when you introduce yourself.
• Ensure that you do not include any information that violates the principles of HIPAA 
(i.e., don’t use the patient’s name or any other identifying information).
• Present the full case. 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.
• Report normal diagnostic results as the name of the test and “normal” (rather than 
specific value). Abnormal results should be reported as a specific value.
Be succinct in your presentation, and do not exceed 8 minutes. Address the following:
• Subjective: What details did the patient provide regarding their personal and 
medical history? What are their symptoms of concern? How long have they been 
experiencing them, and what is the severity? How are their symptoms impacting 
their functioning?
• Objective: What observations did you make during the interview and review of 
systems?
• Assessment: What were your differential diagnoses? Provide a minimum of three 
(3) possible diagnoses. List them from highest to lowest priority. What was your 
primary diagnosis, and why?
• Reflection notes: What would you do differently in a similar patient evaluation? 
Reflect on one social determinant of health according to the HealthyPeople 2030 
(you will need to research) as applied to this case in the realm of psychiatry and 
mental health. As a future advanced provider, what are one health promotion 
activity and one patient education consideration for this patient for 
improving health disparities and inequities in the realm of psychiatry and mental 
health? Demonstrate your critical thinking.	

NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template Sample 

CC (chief complaint): Anxiety

HPI: PW is a 49 year- old Caucasian male who presents to the clinic for psychiatric evaluation. He claims that he is always focused on rules and schedules and aims for perfection, both of which interfere with his ability to complete tasks. He claims that he devotes an excessive amount of time to his job and is reluctant to assign tasks to others until he is certain that they will do the tasks in the manner that he prefers. He has a miserly attitude to spending money, which is based on the belief that it ought to be saved in case of some unforeseen contingency in the future. As such, he has been stuck driving the same car for the last two decades. He claims that he has always suffered from severe anxiety, and that he became aware of it for the first time around 10 years ago. After that, he began drinking heavily as a coping mechanism. Patient states that he went to see a therapist in order to go more deeply into the issues. Ten years ago, he and his wife separated, and he sought inpatient care to begin overcoming his issues when they went their separate ways. He went through a difficult time when he divorced his wife nine years ago. This period of his life was difficult for him. After things settled down and he relocated back to Greenville and he was better able to cope with the challenges he faced. Patient intentionally puts himself in situations with as few unexpected twists and turns as possible. Since  last year, he has been working in different jobs, which has put him in a stressful situation. The patient admits that he has always struggled to get a good night’s rest, and that this has made his problems much worse. He reports that he performs support work and is constantly attempting to solve problems, but at night he focuses on himself and his issues.

Past Psychiatric History:

• General Statement: Patient reports history of anxiety and panic attacks
• Caregivers (if applicable): unknown
• Hospitalizations: Reports past psychiatric hospitalization
• Medication trials: Doxepin
• Psychotherapy or Previous Psychiatric Diagnosis:

Substance Current Use and History: Reports past alcohol use. Denies tobacco or illicit drugs use.

Family Psychiatric/Substance Use History: Mother has a history of depression and anxiety. Reports that several family members had  history of psychiatric diagnoses.

Psychosocial History: Patient was born in Jacksonville FL, raised by both parents and has 1 brother and 1 half brother. Currently lives alone and attends college. Reports that he works as a technical support in Telecomm Industry. Reports a strong support system. Denies history of legal issues. Never served in military. Identifies as heterosexual and is sexually active. Denies history of abuse. Divorced. No children. Averages 4-5 hours of broken sleep.

Medical History: Hypertension, Hashimoto

 

• Current Medications: Amlodipine 5mg PO QD, hydrocortisone 2.5 % cream topically PRN, Levothyroxine mcg tablet 88 mcg PO QD.
• Allergies: NKA

• Reproductive Hx: Identifies as heterosexual and is sexually active. No children.

ROS:

• GENERAL: Denies current fever, chills, or recent weight loss
• HEENT: Denies current vision changes hearing problems, and mouth or throat problems
• SKIN: Denies rash or itching
• CARDIOVASCULAR: Denies chest pain, palpitations or edema
• RESPIRATORY: Denies cough, wheeze or shortness of breath.
• GASTROINTESTINAL: Denies abdominal pain, nausea, vomiting, heartburn
• GENITOURINARY: Denies polyuria, dysuria, or difficulty voiding
• NEUROLOGICAL: Denies dizziness, seizures or stroke
• MUSCULOSKELETAL: Denies muscle pain, joint pain, or back pain
• HEMATOLOGIC: Denies bleeding or history of anemia
• LYMPHATICS: Denies swollen lymph nodes
• ENDOCRINOLOGIC: Denies increased thirst or excessive sweating

Physical exam:

Vital signs: W:161 lbTemp:36.7 °C BP:120/82 HR:69

 

Patient is well-developed and well-nourished, in no acute distress. Patient is not in respiratory distress and there is equal chest expansion bilaterally. Moves all four extremities spontaneously with full range of motion. Grossly normal muscle strength and tone based on observations of spontaneous movements. No tics or tremors evident. No atrophy or abnormal movements. Gait and station observed, which were noted to be not observed.

Diagnostic results:

PHQ9- severe depression

GAD7

 GAD7

 MOCA

Assessment

Mental Status Examination:

Patient appears his stated age. Dressed appropriately for the occasion. Clear and coherent speech with normal pitch and normal volume. Mood is noted as “better than average” and his affect is congruent with his mood.His thought process is logical, coherent, and goal directed. Patient demonstrates no thought disturbances. Alert and oriented to person, place, and time. Denies suicidal thoughts or intent. No specific plan to harm self.  Denies homicidal ideation, intent, or plan. Has appropriate insight into his health condition.  His judgement is intact with appropriate impulsivity. Short-term and long-term memory intact. Fund of knowledge is appropriate for his level of education.

Differential Diagnoses:

Obsessive Compulsive Personality Disorder (OCPD): This is a personality disorder that may be defined by the patient’s strong need for order, neatness, and perfectionism. Individuals who suffer from OCPD are also likely to have a strong want to impose their own standards on the world around them. Individuals who suffer from OCPD are characterized by: a problem communicating feelings; having trouble creating and keeping close relationships; being hardworking, but their drive for perfection may often go in the way of their effectiveness; having a sense of self-righteousness, indignation, and anger; dealing with social isolation; and suffering from the anxiety that accompanies depression (Wheaton & Ward, 2020). Despite the fact that they are drowning in work, people with OCPD often refuse to outsource tasks unless they are certain that others will adhere to the same procedures and practices. It is essential to keep in mind that this “workaholic” mentality is accepted as typical in certain societies; hence, it should not be labeled as obsessive-compulsive personality disorder in such situations (The American Psychiatric Association, 2013). Additionally, many who suffer from obsessive-compulsive personality disorder are notoriously frugal savers who are unable or unwilling to let go of possessions, even if they have no sentimental value (The American Psychiatric Association, 2013). This is the primary diagnosis for patient PW because his presenting symptoms are congruent with those of OCPD.

Generalized anxiety disorder (GAD): This mental illness is defined by continuous and excessive anxiety over a variety of different things. People who suffer from GAD may have an unrealistic fear of negative outcomes and may worry excessively about their finances, health, families, jobs, and other aspects of their lives. People who suffer from generalized anxiety disorder have trouble keeping their worries in check. They may worry more than is necessary about real occurrences or may assume the worst even when there is no obvious cause to be concerned (Iani et al., 2019). 

Panic disorder: This is a mental illness that is characterized by panic attacks occurring often and unexpectedly. These episodes are marked by a sudden surge of panic or discomfort, or a sensation of losing control, even if there is no obvious threat or cause. The physical manifestations of a panic attack sometimes involve sensations that are similar to those of a heart attack, such as tingling, trembling, or a high heart rate (Kim, 2019). Panic attacks might take place at any moment. Many individuals who have panic disorder worry about the prospect of having another attack, and as a result, they may make considerable changes in their lives to eliminate the risk of future attacks. It is possible for panic attacks to occur as often as multiple times a day, or as seldom as once or twice per year.

Reflections: There is nothing I would do differently in a similar patient evaluation because I believe that the preceptor did a good job. It is estimated that around one in one hundred persons in the United States has OCPD (International OCD Foundation, n.d). Personality disorders such as obsessive-compulsive disorder do not have a single identifiable root cause. There are twice as many men as there are women who are diagnosed with OCPD. A person’s likelihood of getting OCPD may be increased by a number of risk factors, including having a preexisting mental health condition, especially anxiety disorder, childhood trauma, and a family history of personality disorders, anxiety, or depression (International OCD Foundation, n.d). It is essential for a PMHNP to encourage patients with OCPD to try not to be self-critical when they are experiencing obsessive thoughts and to develop strategies for self-soothing.

References

American Psychiatric Association. (2013). DSM 5 diagnostic and statistical manual of mental disorders. In DSM 5 Diagnostic and statistical manual of mental disorders (pp. 947-p).

Iani, L., Quinto, R. M., Lauriola, M., Crosta, M. L., & Pozzi, G. (2019). Psychological well-being and distress in patients with generalized anxiety disorder: The roles of positive and negative functioning. PLOS ONE, 14(11), e0225646. https://doi.org/10.1371/journal.pone.0225646

International OCD Foundation. (n.d). Obsessive Compulsive Personality Disorder (OCPD). https://iocdf.org/wp-content/uploads/2014/10/OCPD-Fact-Sheet.pdf

 Kim, Y. (2019). Panic disorder: Current research and management approaches. Psychiatry Investigation, 16(1), 1-3. https://doi.org/10.30773/pi.2019.01.08

Luo, Y., Chen, L., Li, H., Dong, Y., Zhou, X., Qiu, L., Zhang, L., Gao, Y., Zhu, C., Yu, F., & Wang, K. (2020). Do individuals with obsessive-compulsive disorder and obsessive-compulsive personality disorder share similar neural mechanisms of decision-making under ambiguous circumstances? Frontiers in Human Neuroscience, 14. https://doi.org/10.3389/fnhum.2020.585086

Wheaton, M. G., & Ward, H. E. (2020). Intolerance of uncertainty and obsessive-compulsive personality disorder. Personality Disorders: Theory, Research, and Treatment, 11(5), 357-364. https://doi.org/10.1037/per0000396