NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template Example

Subjective:

CC (chief complaint): Sometimes I can’t even hold my own child, I… I, she’s crying and I can’t… I can’t touch her. And when I give her milk, it disgusts me. . I can’t stop crying all the time” “I yell a lot.”

HPI: Mrs. Tilman is a 32-years-old female who presents for psychiatric assessment accompanied by her husband, Rick. She is a new mother with a baby girl Jessica aged two months ago. The husband brought her for assessment because he was much worried about her behavior changes since the birth of the baby. She reports that previously she was good healthwise until recently after having the baby. She has sleep difficulties since the baby cries a lot at night. She has gained a lot of weight since pregnancy, and she wants to lose weight. “I’m terrible. Alright. I look terrible, I feel terrible. My body is bloated. I have lines on my face, bags. I look disgusting”. Nevertheless, her appetite is not good. Although she wants to exercise, she cannot get time because she is busy at home with the baby. “I’m stuck at home. NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template Example I have to take care of the baby all day long”. Mrs. Tildman has cried a lot since Jessica was born and cries a lot. She is just upset with everything and yells a lot. Her relationship with her husband is poor; she has no sexual desire, and whenever the husband wants it, she keeps pushing him away. Mrs. Tilman currently stays at home, and no friends have been seeing her for a while. She was working as a research scientist and secondary school substitute teacher for five years but has resigned to take care of the baby. She denies alcohol or substance abuse. She admits to having suicidal thoughts. Her uncle was an opioid abuser and committed suicide via GSW. He has a history of HTN and was prescribed labetalol 100 mg BD. However, she admits to missing some doses due to poor memory NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template Example. She has no legal history and is allergic to codeine.

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Past Psychiatric History:

• General Statement: Family history of suicide
• Caregivers (if applicable): Stays with Husband, no nanny
• Hospitalizations: No records
• Medication trials: None reported
• Psychotherapy or Previous Psychiatric Diagnosis: None reported

Substance Current Use and History: Denies substance/alcohol abuse.

Family Psychiatric/Substance Use History:  Uncle was an opioid abuser and committed suicide via GSW.

Psychosocial History:

• Medical History: Labetalol 100 mg BD

 

• Current Medications: Labetalol 100 mg BD
• Allergies: Codeine

• Reproductive Hx: A first-time mother of a two-month-old baby girl, Jessica. No sexual motivation, husband has to force her to do it.

ROS:

• GENERAL: Alert with acute distress, has gained weight, has no appetite, and has difficulty remembering.
• HEENT: Denies headache, head trauma, or head injury, No yellow sclerae, double or blurred vision, no hearing problems or use of hearing aids, no tonsillitis history, nose obstructions, or history of nose bleeding, no dental pain, no sore throat, no ulcerations, no dysphagia.
• SKIN: No rash or lesion, no skin itching or abnormal sweating.
• CARDIOVASCULAR: no chest pains, no chest congestion, pressure, or discomfort. No palpitations or murmurs, no edema in lower extremities.
• NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template Example
• RESPIRATORY: No dyspnea, no wheezing or cough, no sputum.
• GASTROINTESTINAL: No nausea or vomiting, no loose stool.
• GENITOURINARY: No urinary frequency, no dysuria, no urinary urgency.
• NEUROLOGICAL: No dizziness or paralysis, no numbness, no unconsciousness or headache.
• MUSCULOSKELETAL: No complaints of muscle or joint pain, no joint pain, no muscle stiffness.
• HEMATOLOGIC:
• LYMPHATICS: No bruising, no anemia or blood sepsis, no bleeding, no hemophilia.
• ENDOCRINOLOGIC: Normal thyroid glands in size, shape, and structure.

Objective:

Diagnostic results: Mrs. Tilman has a height of 5’3, weight of 245 lbs, a temperature of 97.6 F, pulse rate of 97 beats/minute, respiratory rate of 22 breaths/minute, and blood pressure of 149/90 mmHg.

Assessment:

Mental Status Examination: Mrs. Tilman is a 32-year-old woman who is accompanied by her husband for a psychiatric assessment. She appears to have her stated age but with apparent distress. She is a well-oriented X4. She is appropriately dressed, clean, and looks presentable. She is cooperative and maintains eye contact throughout the interview. No abnormal motor behaviors are evident. She has clear but incoherent speech as she makes unclear statements due to distress. She is moody with a full range of affect somewhat restricted, and she is sad. She claims she is upset with everything. No acute psychosis or mood symptoms. No delusional thoughts, but suicidal thoughts are present. She has intrusive thoughts of hurting the baby and the husband, but she removes herself from situations that can lead her to cause them harm. She has memory problems has she has been skipping some HTN doses.

Differential Diagnoses:

Post-Partum Depression (PPD). PPD is classified as a major depressive disorder by the DSM-V that is diagnosed during pregnancy or during the first four weeks postpartum. For a patient to be diagnosed with PPD, they must experience five or more of the following symptoms; experiences of depressed mood indicated by subjective reports of feeling sad or helpless, empty, or appearing tearful (Dekel et al., 2020). Besides, they may have reduced interest in almost everything, significant weight gain, increased or reduced appetite, insomnia almost daily, fatigue almost daily, and feelings of worthlessness. NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template Example They may also have recurrent suicidal thoughts and reduced concentration. In this case, Mr. Tilman complains that the baby cries a lot at night and she can’t sleep. She has gained weight after delivery, and she feels and looks terrible, “my body is bloated .”She has a poor relationship with her husband, no sexual desire, and no interest in outside activities. She cries a lot and yells at her husband. She is also upset with everything. She has a poor appetite and poor memory as she skips taking HTN doses. She has suicidal thoughts of hurting the baby and the husband but tries avoiding it. Sometimes she cannot hold or touch her baby, and it even disgusts her to breatfeed.

Adjustment Disorder with depressed mood: It is a mental disorder characterized by low mood, feelings of hopelessness, or tearfulness. Adjustment disorder is defined as the presence of behavioral or emotional symptoms as a response to stressors which occurs within 3 months after the onset of the stressors. According to the DSM-5, the distress must be intense with an expected response to the stressors. Besides, the symptoms must result in marked distress and impaired functioning of the individual (Maercker & Lorenz, 2018). In this case, the client is a new mother and is adjusting to body changes postpartum and to the roles of motherhood. She claims the baby cries a lot at night and that she looks terrible and bloated; thus, she wants to reduce weight. However, she has no nanny, and the husband cannot hire one. She has also quitted from her writing job because she has to spend the most time on her baby and also has lost interest in the job.

 

Acute Stress Disorder: ASD is caused by a traumatic event and occurs within the first month after the event. The disorder causes severe anxiety and psychological shock followed by other symptoms. The literature demonstrates that individuals with a history of traumatic events who have had PTSD in the past or have a history of mental disorder are at higher risk for ASD. The DSM-5 for diagnosing ASD requires that the stressful event must include severe and traumatic components (Bryant, 2018). ASD is characterized by symptoms such as difficulty in concentration, reduced emotional responsiveness, poor memory, and a sense of detachment. However, though the client experiences some of these symptoms, she has no history of a severely traumatic event NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template Example.

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Reflections:

A comprehensive assessment of mental disorders is considered the standard format for the assessment of mental disorders, substance abuse, and individual needs. A comprehensive assessment gives a summary of the client’s needs which guides in diagnosis and formulation of an individualized care plan. Thus, all the subjective and objective data must be collected to deliver person-centered care. Individualized care in mental health is essential as it benefits both the client and the professional. It enhances the provision of dignified care with respect and compassion hence promoting independence and fulfillment of client life (Coyne et al., 2018). The patient-centered approach also improves work satisfaction and reduces stress levels among the professionals. Nevertheless, the professionals should be culturally competent to meet the individual needs of the client. The client must be ensured of the confidentiality of the information provided to encourage them to open up and share their problems.

References

Bryant, R. A. (2018). The current evidence for acute stress disorder. Current psychiatry reports, 20(12), 1-8.

Coyne, I., Holmström, I., & Söderbäck, M. (2018). Centeredness in healthcare: a concept synthesis of family-centered care, person-centered care, and child-centered care. Journal of pediatric nursing, 42, 45-56.

Dekel, S., Ein-Dor, T., Dishy, G. A., & Mayopoulos, P. A. (2020). Beyond postpartum depression: posttraumatic stress-depressive response following childbirth. Archives of women’s mental health, 23(4), 557-564.

Maercker, A., & Lorenz, L. (2018). Adjustment disorder diagnosis: Improving clinical utility. The World Journal of Biological Psychiatry, 19(sup1), S3-S13 NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template Example.