NRNP/PRAC 6645 Comprehensive Psychiatric Evaluation Note Template
NRNP/PRAC 6645 Comprehensive Psychiatric
Evaluation Note Template
CC (chief complaint): “Chaos at her household”
HPI: Mrs. P is a 40-year-old Iranian female who presented to the psychiatric unit due to chaos in her household. She is accompanied by her 23-year-old daughter for therapy. The patient is an immigrant from Iran, as she moved to the United States 12 years back with 4 of her children as one was left behind at the age of 8 years. She however got her visa 2 years ago and was able to bring the fifth child to the Country. She reports a history of trauma from domestic violence and physical abuse from her husband. The child who was left behind in Iran was also sexually assaulted by her father. The mother feels overwhelmed, hopeless and helpless, as her daughters blame her for the traumatic events. She claims that her daughters are out of control. The family has attended family therapy sessions twice. Mrs. P reports that she has been leading a traditional lifestyle, separate from her children who have adopted a different lifestyle and failing to spend time with her. She is currently disabled from two feet surgeries. She is lonely and helpless as she lives alone NRNP/PRAC 6645 Comprehensive Psychiatric Evaluation Note Template.
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Past Psychiatric History:
- General Statement: The patient is lonely and depressed from living alone without seeing her children every day.
- Caregivers (if applicable): three daughters and two sons, who help support the patient.
- Hospitalizations: Reports a history of foot surgeries done twice.
- Medication trials: None
- Psychotherapy or Previous Psychiatric Diagnosis: The family has a history of traumatic experiences and reports taking part in both individual and family therapy.
Substance Current Use and History: None provided. Can be collected through interviews. Helpful in determining the risks of substance use disorder.
Family Psychiatric/Substance Use History: The patients report a history of physical and sexual abuse from her husband. Her daughter who was left in Iran, was also sexually and physically abused by her father.
Psychosocial History: Mrs. P was born and raised in Iran. She was married to an abusive husband the made her migrate to the United States. She has five children, three daughters, and two sons. She is Muslim, with a traditional lifestyle. She likes watching religious teaching and playing video games when alone.
Medical History:
- Current Medications: None. This information is important in selecting a medication for the management of the present mental illness.
- Allergies: None
- Reproductive Hx: Heterosexual. Normal birth of five children, two sons, and three daughters.
ROS: None provided. A review of systems through interviewing the patient is crucial in ruling out comorbid medical conditions.
Physical exam: The patient’s vitals and examination of the musculoskeletal system are necessary for further assessment of her disability from the previous surgeries NRNP/PRAC 6645 Comprehensive Psychiatric Evaluation Note Template.
Diagnostic results: The following lab works would be necessary to help rule out comorbid medical conditions: TSH, CMP, CBC, and Testing for infections like hep C, and HIV. The Beck Depressive Inventory and Hamilton-anxiety rating scale can be utilized among all family members for the development of differential diagnosis (Salas-Wright et al., 2018).
Assessment
Mental Status Examination: The mental status examination of the patient and her daughter was not provided. However, from the information shared in the video, they seemed both well-groomed and appropriately oriented in time place, and person. They were cooperative during the interview, maintaining eye contact and appropriate use of other nonverbal cues. The mood was appropriate for the situation. The affect was full range. Logical thought process. Intact short-term and long-term memory. Appropriate judgment. They however both displayed depressed and anxious moods. No history of hallucination, suicidal or homicidal ideation NRNP/PRAC 6645 Comprehensive Psychiatric Evaluation Note Template.
Differential Diagnoses:
- Major depressive disorder: The patient reports feeling lonely, hopeless, and helpless which are indicating signs of MDD (Kennedy, 2008). She also reports a history of trauma which might have triggered the depression.
- Reactive attachment disorder: The patient reports that her daughters are out of control. One of them got married, while the others are leading an independent lifestyle leaving her alone with the last-born son (Bruce et al., 2018).
- Adjustment disorder: The patient’s oldest daughter was sexually abused by her father for two years when she was left in Iran by her mother. Moving to the United States might have contributed to a combination of mental and emotional disturbances including depression and anxiety (O’Donnell et al., 2019).
Case Formulation and Treatment Plan:
The case involves a depressed mother who feels lonely and helpless as she is disabled and living with only her youngest son, with her other four children away from her home. She feels like her daughters are out of control, leading to a chaotic situation (Salas-Wright et al., 2018).
Treatment Plan: Psychotherapeutic interventions including family therapy and cognitive behavioral individual therapy is appropriate to help the family overcome their difficulties in communication and manage their history of trauma (Franz & McKinney, 2018).
Reflections: The provided video demonstrates a middle age Iranian female, as a victim of physical and sexual abuse, together with her firstborn daughter. She moved to the United States, where she had her other four children, and is currently experiencing a chaotic household. The main cause of the chaotic environment is the difference in their lifestyle, as their mother follows the Muslin value, while her daughters have adopted the western lifestyle (Franz & McKinney, 2018). However, with continuous family therapy, they will develop appropriate skills to help promote a common understanding and support each other in overcoming their history of trauma NRNP/PRAC 6645 Comprehensive Psychiatric Evaluation Note Template.
References
Bruce, M., Young, D., Turnbull, S., Rooksby, M., Chadwick, G., Oates, C., Nelson, R., Young-Southward, G., Haig, C., & Minnis, H. (2018). Reactive Attachment Disorder in maltreated young children in foster care. Attachment & Human Development, 21(2), 152–169. https://doi.org/10.1080/14616734.2018.1499211
Franz, A. O., & McKinney, C. (2018). Parental and Child Psychopathology: Moderated Mediation by Gender and Parent–Child Relationship Quality. Child Psychiatry & Human Development, 49(6), 843–852. https://doi.org/10.1007/s10578-018-0801-0
Kennedy, S. H. (2008). Core symptoms of major depressive disorder: relevance to diagnosis and treatment. Dialogues in Clinical Neuroscience, 10(3), 271–277. https://doi.org/10.31887/dcns.2008.10.3/shkennedy
O’Donnell, M. L., Agathos, J. A., Metcalf, O., Gibson, K., & Lau, W. (2019). Adjustment Disorder: Current Developments and Future Directions. International Journal of Environmental Research and Public Health, 16(14), 2537. https://doi.org/10.3390/ijerph16142537
Salas-Wright, C. P., Vaughn, M. G., Goings, T. C., Miller, D. P., & Schwartz, S. J. (2018). Immigrants and mental disorders in the united states: New evidence on the healthy migrant hypothesis. Psychiatry Research, 267, 438–445. https://doi.org/10.1016/j.psychres.2018.06.039 NRNP/PRAC 6645 Comprehensive Psychiatric Evaluation Note Template