Nrnpprac 6635 Comprehensive Psychiatric Evaluation Example

Nrnpprac 6635 Comprehensive Psychiatric Evaluation Exemplarinstructio

Review the detailed instructions and guidelines for completing a comprehensive psychiatric evaluation. The assignment involves documenting the subjective history, objective findings, assessment, differential diagnoses, and reflection on the case. Emphasis is placed on thorough documentation, critical thinking, and supporting evidence from literature, all formatted according to APA 7th edition standards.

Follow the detailed structure including chief complaint, history of present illness, past psychiatric history, medication trials, psychotherapy, substance use, family psychiatric history, social, medical, reproductive history, review of systems, physical exam, diagnostic results, mental status exam, differential diagnoses with supporting evidence, and reflective discussion on learnings, ethics, social determinants, and health promotion. Incorporate at least three peer-reviewed sources to support your analysis.

Paper For Above instruction

Introduction

Comprehensive psychiatric evaluations are critical tools in clinical mental health practice. They provide a structured approach to understanding a patient's mental health history, current presentation, and differential diagnoses, guiding effective treatment planning. This case report exemplifies a thorough psychiatric assessment, integrating patient history, mental status examination (MSE), and evidence-based differential diagnoses to arrive at an accurate clinical impression. Furthermore, the reflection component underscores the importance of ethical considerations, social determinants of health, and health promotion strategies in psychiatric practice.

Subjective Section

The patient, Mr. A, is a 45-year-old African American male who presents for a psychiatric evaluation primarily due to increased feelings of sadness, hopelessness, and diminished interest in activities over the past two months. He reports experiencing sleep disturbances, fatigue, and difficulty concentrating. These symptoms have worsened since his recent loss of employment, which he attributes to his declining mental health. Mr. A is currently prescribed sertraline 50 mg daily, which he reports taking for the past month without noticeable benefit. His primary care provider referred him for further psychiatric assessment and management.

Mr. A’s psychiatric review of symptoms reveals persistent low mood, anhedonia, fatigue, and sleep disruption. He denies any suicidal or homicidal ideation but admits feeling worthless at times. There are no reports of manic or psychotic symptoms. He denies recent substance use, including alcohol, tobacco, or illicit drugs. His past psychiatric history includes a diagnosis of depression at age 30, for which he received intermittent therapy but no hospitalization. He has no history of outpatient psychotherapy or previous psychiatric hospitalizations.

His substance use history is notable for minimal alcohol consumption during social occasions; he reports no withdrawal symptoms. Family psychiatric history indicates his mother experienced recurrent major depressive episodes, and his father struggled with alcohol dependence. Socially, Mr. A resides alone, is divorced, and has one adult child. He completed high school and worked as a factory worker before his recent unemployment. He reports limited recreational activities and indicates a history of childhood trauma involving emotional neglect.

Medical history is significant for hypertension, managed with lisinopril. He reports allergies to penicillin, resulting in hives. Reproductive history is not applicable. His review of systems highlights no additional complaints. His physical exam is unremarkable, with vital signs within normal limits and no abnormal findings on systemic review.

Objective

The physical exam reveals a well-groomed male appearing his stated age. Vital signs are: BP 128/78 mm Hg, pulse 76 bpm, temperature 98.6°F, respiration 16/min. Examination of systems pertinent to depression shows no abnormalities. Diagnostic tests include a CBC, thyroid panel, and vitamin D level—all within normal limits. An ECG was performed to evaluate cardiovascular status, with no abnormalities noted.

Assessment

The mental status examination shows a cooperatively engaged patient, dressed appropriately with fair eye contact. He displays a sad mood with a constricted affect. Speech is normal in rate and volume. Thought processes are logical and goal-directed; thought content reveals feelings of worthlessness but no delusions. He denies hallucinations or perceptual disturbances. Cognition appears intact, with good concentration and recent and remote memory preserved. Insight and judgment are fair; he denies current suicidal or homicidal ideation.

Differential Diagnoses

The primary diagnosis under consideration is Major Depressive Disorder (MDD), based on DSM-5-TR criteria: persistent depressed mood, anhedonia, sleep disturbance, fatigue, concentration problems, and feelings of worthlessness present for at least two weeks. Differential diagnoses include:

• Adjustment Disorder with Depressed Mood: Less likely, as symptoms have persisted beyond six months and lack a clear precipitant beyond recent job loss.
• Grief Reaction / Bereavement: Unlikely, as the symptom duration exceeds typical grief timelines and includes pervasive feelings of worthlessness not usually seen in normal grief reactions.
• Bipolar Disorder, depressive episode: No history of manic or hypomanic episodes; mood is consistently depressed.

Supporting evidence from DSM-5-TR suggests that Mr. A’s presentation aligns most with MDD, as he exhibits key symptoms over a two-month period that significantly impair functioning. Laboratory results are unremarkable, ruling out thyroid dysfunction or nutritional deficiencies that could mimic depressive symptoms. The primary diagnosis is reinforced by his history and symptomatology, combined with the absence of features suggestive of other mood or psychotic disorders.

Reflection

This case underscores the importance of integrating clinical judgment with evidence-based guidelines while considering social and cultural contexts. I learned that a comprehensive assessment must include an evaluation of social determinants—such as employment status, social support, and trauma history—that influence mental health outcomes. Recognizing the impact of socioeconomic factors like unemployment is crucial for tailoring interventions.

Ethically, clinicians must ensure culturally sensitive care, considering the patient’s background and potential stigmas associated with mental illness in the African American community. Legally, confidentiality and informed consent are fundamental, but clinicians also have a duty to address the broader social issues affecting health—such as access to care and social support systems.

From a health promotion perspective, early identification and intervention can prevent escalation and improve prognosis. In Mr. A’s case, coordination with social services and referral to therapy could enhance recovery. Moving forward, I would focus on comprehensive care, including psychoeducation about depression, lifestyle modifications, and community resources to support social reintegration.

References

• American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders (5th ed., text rev.; DSM-5-TR). American Psychiatric Association.
• Kuehner, C. (2017). Why is depression more common among women than among men? The Lancet Psychiatry, 4(2), 146-158. https://doi.org/10.1016/S2215-0366(16)30263-2
• Malhi, G. S., & Mann, J. J. (2018). Depression. The Lancet, 392(10161), 2299-2312. https://doi.org/10.1016/S0140-6736(18)31948-2
• Harvard Medical School. (2019). Recognizing Depression. Harvard Health Publishing. https://www.health.harvard.edu/mind-and-mood/recognizing-depression
• World Health Organization. (2021). Depression. WHO Fact Sheet. https://www.who.int/news-room/fact-sheets/detail/depression