Psychiatric Evaluation Of A Patient With Major Depressive Disorder Assignment
Psychiatric Evaluation Of A Patient With Major Depressive Disorder Assignment
psychiatric evaluation of a patient with major depressive disorder
The psychiatric evaluation of a patient with major depressive disorder is designed to gather the necessary information to assess the client’s condition as well as to begin establishing a therapeutic advanced practice psychiatric mental health nurse-client relationship. The information gathered during this process will allow the advanced practice psychiatric mental health nurse to develop a diagnosis from which a precise treatment plan is prescribed.
Psychiatric Evaluation (AKA Psychiatric History and Physical)
IMPORTANT: Notes are to represent realistic patient with * Mayor Depression Disorder*
These Psych Evals will serve to stimulate discussion, questions, and critique by peers and instructors. Psych Evals are to be posted in weeks 3, 7, and 11. A meaningful response is one that demonstrates critical thought. Refer to the Carlat, Zuckerman, and Kaplan & Sadock (Ch. 5) texts for assistance.
The evaluation is to be read by the clinical preceptor. Please include additional information in italics, for instance, what you may have done differently than your preceptor, or in addition to what was done.
Purpose: The psychiatric evaluation is designed to gather necessary information to assess the client’s condition as well as to begin establishing a therapeutic advanced practice psychiatric mental health nurse – client relationship. The information gathered during this process will allow the advanced practice psychiatric mental health nurse to develop a diagnosis from which a precise treatment plan is prescribed.
Format should be in the H & P format outlined below. Grading rubric is also below:
H & P FORMAT: (Note: This example is not exhaustive and yours must include additional data such as elaboration of rationale, neurobiology, or other information important for an academic exercise but not necessarily appropriate for a clinical document in practice.)
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DEMOGRAPHIC INFORMATION
IDENTIFYING INFORMATION: The patient is a (age, marital, ethnicity, gender) who presents today for a psychiatric eval (reason/referral). Sources of information for this evaluation include pt report, collateral info from.., available old records. The patient was/was not able to give an account of his/her activities/life events/symptoms in a chronological order.
SUBJECTIVE DATA (what the patient says to yo)
CC:
HISTORY OF PRESENT ILLNESS: (SUBJECTIVE).
Should use the OLDCARTS acronym when trying to elicit characteristics of symptoms.
Remember to include pertinent negatives.
HPI MUST contain validation of diagnoses. Include your pertinent review of systems (ROS) here. You do not need to do an exhaustive review, only what is pertinent to the patient’s CC. Frequent symptoms that are reviewed in a psych eval are constitutional, neurological. Remember that the ROS is SUBJECTIVE. This is not the place for assessment findings ie. Lungs clear, BS present all 4 quad, skin is clear, appears to be responding to internal stimuli, etc… Psychiatric Evaluation Of A Patient With Major Depressive Disorder Assignment
PAST PSYCHIATRIC HISTORY:
Be sure to include previous treatment, response to treatment, and explore the seriousness and context of self harm or suicide attempts. Ask about hospitalizations or partial hospitalizations. If they have been diagnosed with psychiatric illness before, ask what type of provider made the diagnosis and why. This helps you understand the patient’s insight and understanding.
Psychotherapy
Hospitalizations
Suicide attempts
PREVIOUS PSYCHIATRIC MEDICATIONS: Question carefully about length of trials, dose, why d/c
CURRENT MEDICATIONS:
SUBSTANCE USE/ ADDICTIVE BEHAVIORS: If + is a higher risk for suicide. First use and circumstances surrounding use, consequences of use (social, legal, economic, relational, health), last use, pattern, CAGE- Cut down-Annoy-Guilt-Eyeopener. Detox/Rehab? How do they handle stress? How often is use, how much, what is the most you did in one day? Be wary of denial/minimization. Any withdrawal S&S? Ask specifically about classes of drugs , illicit and/or prescribed (marijuana, ETOH, stimulants like cocaine, meth, or Ritalin, opiates, synthetics, bath salts, designer drugs, and non controlled like gabapentin, Seroquel, or artane), nicotine, or caffeine (also comes in pill form) and route (“have you ever snorted anything? Injected anything? Taken pills that were not prescribed to you or taken your prescription other than as directed?” Routes include insufflation (snorting) IV, oral, sublingual, transdermal, anal, or vaginal).
Inquire about eating, spending, gaming, gambling patterns. May also begin to inquire about sexual habits.
FAMILY PSYCHIATRIC HISTORY:
Completed suicides
Good response to meds? If yes, which ones?
Dx by psych or self diagnosed?
MEDICAL HISTORY: Head injury, seizures, EEG, CT scan, review of pertinent labs, Current Medical Problems, chronic illnesses (lupus, fibromyalgia, arthritis, parkinsons, thyroid issues, cardiac disease, HTN, diabetes, cancer) any meds that have caused s&s? New onset of illness that causes stress? Last period, pregnancy test? Eating disorders? Sexual history
Medical Illnesses
History of Med Illness
Surgical history
Allergies
PSYCHOSOCIAL:
Ability to work and love. (work=ability to structure daily activities, meet expectations, relate adequately to peers and supervisors, take on level of responsibility. Long term relationship=ability to attend to others needs, control impulses, make a commitment.)
Childhood/developmental history, family of origin, siblings, birth order, relational status, marital status-how long, children, housing situation, education, employment, abuse, religious/spiritual beliefs, legal(consider antisocial or substance abuse if extensive)
Born and raised where/by whom/siblings/relationship status
Education/performance
Living situation
Marriage/relationships
Children
Employment
Legal
Abuse
ASSETS/STRESSORS:
OBJECTIVE DATA
MENTAL STATUS EXAM: (OBJECTIVE).
Must be in narrative form.
Include all elements and be as descriptive as possible. Please refer to Kaplan and Sadock text, Ch. 5, pgs. 201-205 and the Carlat or Robinson texts.
Mental Status Exam Elements- All Borderline Subjects Are Tough Troubled Characters
A- Appearance
Height, build, hair color, style, facial hair, body modifications, facial features, scars, grooming, hygiene, odors, clothing, make-up, impression of general appearance and memorable aspects.
B- Behavior
Attitude
Motor activity
Psychiatric Evaluation Of A Patient With Major Depressive Disorder Assignment
S- Speech
General quality
Fluency
Amount
Rate
Tone
Volume
Prosody
Spontaneity or Latency
A- Affect
Qualities of Affect
Stability
Appropriateness
Range
Intensity
Mood as defined by patient. Usually in quotation marks
T- Thought process
Flow and processing of thought. Examples:
Circumstantiality
Clang associations
Fight of ideas
Perseveration
Thought blocking
T- Thought content
Suicidal ideation (SI), Homicidal ideation (HI), Violent ideation (VI). If + comment on intent, plan, and preparation
Psychotic ideation or perceptual disturbances. Examples:
Delusions or hallucinations
Obsessional thoughts
Compulsions
Ideas of reference
Paranoia (suspiciousness)
Significant themes related to diagnosis
C- Cognitive exam – consider educational attainment when interpreting results.
Alertness
Orientation
Concentration
Memory (long and short term)
Calculation
Fund of knowledge
Abstract reasoning
Insight
Judgment
PHYSICAL EXAM: (VS, HT, WT, LABWORK AND OTHER DIAGNOSTICS)
This section will vary in scope dependent on the setting.
DIFFERENTIAL:
DIAGNOSTIC IMPRESSION WITH FORMULATION:
RISK ASSESSMENT:
RECOMMENDATIONS AND PLAN WITH GOALS AND RATIONALES WITH NEUROBIOLOGY:
When providing treatment recommendations, be as holistic and comprehensive as possible. When describing rationales for these recommendations be as specific as possible. It is not sufficient to explain that a treatment is FDA indicated and then to outline the mechanism of action of the drug. Explain why you (or your preceptor) chose a particular drug or treatment in lieu of another. For instance, why escitalopram instead of citalopram or fluoxetine, or sertraline, etc…?
Remember to include all information that was actually done but also include, in italics, other or additional actions you would have taken or things you would have done differently.
Psychiatric Evaluation Of A Patient With Major Depressive Disorder Assignment
Grading Rubric for Psychiatric Evaluations and Psychiatric Case Presentations
| Category | Excellent | |
| Demographic Data | 5
Includes identifying information including initials, age, gender, ethnicity. Primary source of information and reliability as well as reason for referral and patient understanding of referral are clear. |
|
| Subjective Data
History of Present Illness (HPI) |
20
CC is clear, concise and verbatim from pt. HPI is thorough yet concise and provides a chronological account of symptoms and contextual factors that are sufficiently descriptive (oldcarts) to validate Dx per DSM-5 criteria. All pertinent negatives are included. A longitudinal course of illness is clear. Current psychiatric medications and response are included.
|
|
| Past Psychiatric History | 5
PPH contains all previous treatment including previous Dx, hospitalizations, outpatient treatments, suicide attempts, self-harm, and previous medications with detailed trial and response history. Pertinent negatives are also included. |
|
| Substance Use History | 5
Complete substance use history is documented. Pertinent negatives are clear evidenced by appropriate pt. responses ie. “denies”. Age of onset, duration, frequency/pattern of use, route of administration, last use, consequences of use. Not limited to illicit substances. Inclusive of addictive behavioral patterns. |
|
| Past Medical History and Review of Systems (ROS) | 5
Medical history includes previous and current medical problems, surgeries, and allergies. ROS is germane to the presenting psychiatric problems and is free from objective assessment data ie. “lungs clear” “BS present”. |
|
| Family History Psychosocial and Developmental History | 10
Family Hx includes identified relational status with current or historical psych illness, treatments, responses, suicides, or self-harm. Indication if biologically related. Dev’t Hx includes info regarding family of origin, siblings, birth order, family dynamics, relational patterns and status, educational, employment, abuse, spirituality, legal, military. Dev’t milestones for child & adolescents are included |
|
| Objective Data
Mental Status Exam Physical Exam (as appropriate) vital signs, height, weight, labs or other relevant diagnostics. |
15
MSE contains all elements as outlined in addendum.. Is in narrative form and effectively and vividly describes the patient’s presentation. Concrete examples of all assessment results are included ie. “able to correctly interpret 2/3 simple proverbs” to validate documentation of “abstract thought intact”.
|
|
| Assessment
|
10
Differential is pertinent to S&S, formulation contains evidence of critical thought and subject knowledge, and reasonable diagnoses are made per DSM-5. Clearly met criteria for diagnoses tendered are explicit in the HPI description and substantiated with the MSE. |
|
| Plan
|
15
Evidence-based treatment plan is presented with detailed rationales. Level of detail reflects the student’s ability to choose treatments based not only on FDA approval or current evidence but also the nuances and unique characteristics of each. Treatment plan is holistic and comprehensive. There is strong evidence of the student’s synthesis of information and critical thought. |
|
| Writing, Support, APA | 5
The format is consistent with the example provided in the course. Strong, recent (5-7 years), scholarly, peer- reviewed support of topics. No grammar, spelling, and punctuation errors. Writing mechanics are consistent with formal scholarly work. No errors in APA style based upon the required APA manuals listed on the course syllabi. |
|
Rubric Addendum
Mental Status Exam Elements- All Borderline Subjects Are Tough Troubled Character
- Appearance
Height, build, hair color, style, facial hair, body modifications, facial features, scars, grooming, hygiene, odors, clothing, make-up, impression of general appearance and memorable aspects.
B- Behavior
Attitude
Motor activity
S- Speech
General quality
Fluency
Amount
Rate
Tone
Volume
Prosody
Spontaneity or Latency
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- Affect
Qualities of Affect
Stability
Appropriateness
Range
Intensity
Mood as defined by patient. Usually in quotation marks
T- Thought process
Flow and processing of thought. Examples:
Circumstantiality
Clang associations
Fight of ideas
Perseveration
Thought blocking
T- Thought content
Suicidal ideation (SI), Homicidal ideation (HI), Violent ideation (VI). If + comment on intent, plan, and preparation
Psychotic ideation or perceptual disturbances. Examples: Psychiatric Evaluation Of A Patient With Major Depressive Disorder Assignment
Delusions or hallucinations
Obsessional thoughts
Compulsions
Ideas of reference
Paranoia (suspiciousness)
Significant themes related to diagnosis
C-Cognitive exam – consider educational attainment when interpreting results.
Alertness
Orientation
Concentration
Memory (long and short term)
Calculation
Fund of knowledge
Abstract reasoning
Insight
Judgment
Psychiatric Evaluation Of A Patient With Major Depressive Disorder Assignment
