Posted: April 24th, 2023

Comprehensive Psychiatric Evaluation Template

Comprehensive Psychiatric Evaluation Template
With Psychotherapy Note

Encounter date: __20/04/2023_______________
Patient Initials: __P.S.____ Gender: M/F/Transgender _Female___ Age: __23___ Race: _Caucasian____ Ethnicity __White__
Reason for Seeking Health Care: _ “For the past two months, my mood swings have been pretty intense.
I can be joyful one minute and start crying for no apparent cause the next. My emotions are out of control, and I think there is something wrong with me.”
HPI: _ The patient is a 23-year-old female who presents to the clinic with a chief complaint of experiencing extreme mood swings over the past two months. She admitted having episodes of elevated mood and energy, during which she feels on top of the world, has increased self-confidence, and is very talkative. During these episodes, she admitted that she feels like she can accomplish anything and that nothing can stop her. She admitted that these episodes typically last for 5-7 days. The patient also admitted that she experiences episodes of depression, during which she feels sad, hopeless, and worthless. During these episodes, she has difficulty sleeping, loses interest in activities she used to enjoy, and has trouble concentrating. These episodes typically last for 2-3 weeks. The patient admitted that she has been going through these mood swings for the past two months and that they are making it difficult for her to operate in both her personal and professional lives. She admitted that she is unable to foresee when the episodes will happen and that they tend to start unexpectedly. She admits that she has not felt any respite from her symptoms and that they are getting worse. The patient admitted that she has not found anything that reliably relieves her symptoms. She admitted to trying various coping strategies, such as exercise and mindfulness practices, but has not found them to be effective. The patient admitted that stress seems to trigger her episodes, but she also experiences mood swings without any identifiable trigger. On a scale of 1-10, the patient rates her manic symptoms as a 9 and her depressive symptoms as an 8.
SI/HI: The patient admitted having infrequent suicidal thoughts while suffering from depression episodes, but she denied having any such ideas at the moment.

Sleep: __ The patient admitted having trouble falling and maintaining sleep throughout both manic and depressed periods. The patient also admitted a diminished desire for sleep during manic episodes, usually going days without sleep.
Appetite: The patient admitted experiencing changes in appetite during mood episodes. During manic episodes, the patient admitted to an increased appetite and cravings for sugary and high-carbohydrate foods. During depressive episodes, the patient admitted to decreased appetite and loss of interest in food.
Allergies (Drug/Food/Latex/Environmental/Herbal): ___ The patient admitted to being mildly allergic to dust and mold and experiences symptoms of sneezing, congestion, and itchy eyes when exposed to these allergens. The patient admits to no known allergies to any drug, food, latex, or herbal supplements.

Current perception of Health: Excellent Good Fair Poor
Psychiatric History:
Inpatient hospitalizations:
Date Hospital Diagnoses Length of Stay
None

None
None
None

Outpatient psychiatric treatment:
Date Hospital Diagnoses Length of Stay
None
None
None
None

None
None
None
None

Detox/Inpatient substance treatment:
Date Hospital Diagnoses Length of Stay
None
None
None
None

None
None
None
None

History of suicide attempts and/or self-injurious behaviors: __ The patient denies a history of suicide attempts during past depressive episodes. The patient admitted to a history of self-injurious behaviors, such as cutting herself on her thighs, during both manic and depressive episodes.
Past Medical History
● Major/Chronic Illnesses___ The patient denied a history of any medical condition, chronic or major.
● Trauma/Injury ___ The patient admits to a history of physical and emotional trauma during childhood, including abuse and neglect from her cocaine-addicted parents.
● Hospitalizations ____The patient denied having a history of hospitalization for any illness, maniac, or depressed episodes.
● Past Surgical History__ The patient denied a history of surgical procedures.
Current psychotropic medications:

___________None______________________________ ________________________________
_________________________________________

Current prescription medications:

___________None_________________ ________________________________
_________________________________________ ________________________________
_________________________________________ ________________________________

OTC/Nutritionals/Herbal/Complementary therapy:

_____________________None____________________ ________________________________
_________________________________________ ________________________________

Substance use: (alcohol, marijuana, cocaine, caffeine, cigarettes)

Substance Amount Frequency Length of Use
None None None None
None None None None
None None None None
None None None None

Family Psychiatric History:
● The patient’s mother, who is 48 years old currently, has a history of anxiety and depression and has been treated with medication and therapy in the past. She is also a cocaine addict.
● The patient’s father who died when he was 50 years old from a cocaine overdose had a history of depression, schizophrenia, and cocaine addiction.
● The patient’s maternal aunt, who is 42 years old currently, has a history of bipolar disorder and has been hospitalized multiple times for manic episodes.
● The patient’s paternal grandfather, who passed away at the age of 75, had a history of depression and alcohol use disorder.
● The patient’s sister, who is 30 years old currently, has a diagnosis of major depressive disorder and has attempted suicide in the past.
Social History
Lives: Single-family House/Condo/ with stairs: ___three-bedroom apartment________ Marital Status: __ Single_____
Education: ______ Bachelor of Education _____
Employment Status: __ Employed ___ Current/Previous occupation type: 7th grade teacher.
Exposure to: __Denies _Smoke_ _Denies__ ETOH __Denies_ Recreational Drug Use: Denies
Sexual Orientation: ____Heterosexual___ Sexual Activity: __Active__ Contraception Use: Nexplanon inserted on her left upper arm to be removed after 3 years. She is currently in her second year.
Family Composition: Family/Mother/Father/Alone: ___The patient’s mother and older sister are alive but they have not been in touch with each other for over 3 years.
Other: (Place of birth, childhood hx, legal, living situations, hobbies, abuse hx, trauma, violence, social network, marital hx):_ _The patient was born in Miami, Florida. The patient admitted that she had a difficult childhood as her parents were both cocaine addicts and often neglected and verbally abused her and her older sister. She admitted she experienced bullying at school and had difficulty making friends. The patient denied having any legal issues or criminal records. The patient admitted to living in a 3-bedroom apartment with her current boyfriend. She admitted to loving her job as a school teacher as she loves children. She admitted due to her manic and depressive episodes she has been having difficulty at work and in her relationship. The patient admitted that she normally enjoys reading and playing video games as a way to relax and cope with stress. The patient admitted experiencing emotional abuse from their parents during childhood, which has contributed to her mental health struggles. The patient admitted to having a small support system consisting of her boyfriend and a few close friends. She denied ever having been married.
Health Maintenance
Screening Tests (submit with SOAP note): Depression, Anxiety, ADHD, Autism, Psychosis, Dementia
● The patient was screened for depression using the Patient Health Questionnaire-9 (PHQ-9) on the 12th of September 2021. The test results were a score of 5, indicating a negative for depression.
● The patient was screened for anxiety using the Generalized Anxiety Disorder 7-item (GAD-7) on the 4th of June 2020. The test results were a score of 3, indicating no anxiety.
● The patient was screened for ADHD using the Adult ADHD Self-Report Scale (ASRS-v1.1) on the 9th of March 2022. The test results were a score of 8, indicating a negative likelihood of ADHD.
● The patient admitted to receiving a routine physical examination on the 20th of March 2022, which included checking her blood pressure, heart rate, temperature, weight, and height. All results were within normal ranges.
● The patient admitted that she underwent a comprehensive eye examination on the 16th of January 2022, which included a vision test, eye pressure test, and dilation of the pupils. The test results were normal, and the patient was advised to schedule a follow-up examination after one year.
Exposures: The patient denied being exposed to any harmful substances
Immunization HX:
● The patient admitted she received a seasonal flu vaccine on the 1st of October 2022 to protect against the influenza virus. The patient admitted all her immunizations are current.
● The patient admitted she received a hepatitis A vaccine on the 1st of February 2023 as she was planning to travel to a country where hepatitis A is prevalent.
Review of Systems (at least 3 areas per system):
General: The patient admits feeling well overall, with no fever, chills, or night sweats. The patient denies any recent weight loss or gain, fatigue, or weakness.
HEENT: The patient denies having a headache, dizziness, or dizziness. The patient denies any history of head fractures or concussions. The patient denies any alterations in vision or eye discomfort, including no eye redness, itching, or discharge. The patient denies no hearing loss, ringing in the ears, or ear pain. The patient denies any history of nasal congestion, sinus pressure, or nosebleeds. The patient denies no difficulty swallowing, sore throat, or hoarseness.
Neck: The patient denies no neck pain or stiffness. She denies a history of neck injury, lymph node enlargement, or thyroid disease.
Lungs: The patient denies any cough, shortness of breath, wheezing, or chest pain. She denies a history of asthma or chronic obstructive pulmonary disease (COPD).
Cardiovascular: The patient denies any chest pain, palpitations, or shortness of breath with exertion. She denies a history of heart disease or hypertension.
Breast: The patient denies no breast lumps, pain, or discharge. She denies a family history of breast cancer.
GI: The patient denies any abdominal pain, nausea, vomiting, or diarrhea. She denies a history of liver disease or inflammatory bowel disease (IBD).
Male/female genital: The patient denies any genital sores, discharge, or pain. She denies a history of sexually transmitted infections (STIs).
GU: The patient denies any urinary frequency, urgency, or pain. She denies a history of kidney disease or urinary tract infections (UTIs).
Neuro: The patient denies any seizures, weakness, numbness, or tingling. She denies a history of migraines or multiple sclerosis (MS).
Musculoskeletal: The patient denies no joint pain, swelling, or stiffness. There is no history of arthritis or osteoporosis.
Activity & Exercise: The patient admits that whenever she can she enjoys engaging in regular physical activity, with no limitations or difficulties.
Psychosocial: The patient admits feeling unwell mentally, with symptoms of depression, maniac, and mood swings. The patient admits to having a good support system for her boyfriend and friends.
Derm: The patient denies any skin rash, lesions, or changes in moles. There is no history of skin cancer or psoriasis.
Nutrition: The patient admitted having a healthy diet, with no food allergies or intolerances. The patient denies any recent weight loss or gain.
Sleep/Rest: The patient admitted some difficulty with sleep and rest in both manic and depressive episodes. She admitted to feeling tired throughout the day, but also experiencing periods of insomnia where she has difficulty falling or staying asleep.
LMP: The patient admits to having regular menstrual cycles that come every 28 days and last for 4 days, with no significant pain or irregularities.
STI Hx: The patient denies any history of sexually transmitted infections (STIs).

Physical Exam
BP: 120/70 mmHg measured while patient was seated TPR _96.2F taken orally___ HR: __75___ RR: _19___Ht. _6’2____ Wt. 70 kg BMI (percentile) _19.8 kg/m2 (15%, Healthy weight) Pain: No pain reported at the moment
General: The patient is clean, and wearing a pink dress. She is alert and oriented to person, place, and time. She appears comfortable and in no acute distress.
HEENT: Head: The patient’s head appears normocephalic and atraumatic, without any palpable masses or tenderness on examination, no signs of alopecia, with evenly distributed hair, and no signs of bruises or wounds on the scalp. Eyes: No conjunctival redness, swelling, or discharge, pupils are equal and reactive to light, no visual field deficits noted, extraocular movements are intact, fundoscopic exam shows clear media and normal optic disc and retina. Ears: Auricles are symmetrical and without signs of trauma, inflammation, or discharge, external auditory canals are patent without cerumen impaction, and tympanic membranes appear clear and intact without signs of bulging retraction, or fluid behind the ear drum. Nose: No nasal deformities or septal malalignment noted, no signs of mucosal erythema, discharge, or bleeding, and no nasal polyps or masses. Throat: lips, tongue, buccal mucosa, and gums are without lesions or swelling, tonsils are not enlarged or erythematous, the uvula is center, and the soft palate rises symmetrically with phonation, no pain or tenderness with swallowing.
Neck: The neck is supple with a full range of motion. No lymphadenopathy or thyroid enlargement is palpated.
Pulmonary: Chest appears symmetrical and there are no visible signs of respiratory distress, tactile fremitus is equal bilaterally, and there are no areas of tenderness or masses palpated, and lungs are clear to auscultation bilaterally with good air movement.
Cardiovascular: Heart sounds are regular with no murmurs, rubs, or gallops. No jugular venous distension is present. Peripheral pulses are strong and symmetrical.
Breast: No masses or nodules were palpated. No nipple discharge or skin changes were noted.
GI: Abdomen is soft and nontender to palpation with no organomegaly or masses appreciated. Bowel sounds are present in all quadrants.
Male/female genital: External genitalia appears right color, without lesions, with no signs of inflammation or irritation. Internal examination reveals a cervix with no signs of inflammation, lesions, or discharge. The uterus is retroverted and non-tender on palpation.
GU: No suprapubic tenderness or costovertebral angle tenderness is appreciated. No hematuria was noted. Urine shows no signs of infection, with normal levels of pH, and specific gravity.
Neuro: Cranial nerves II-XII are grossly unimpaired as evidenced by the patient’s ability to track with her eyes, and follow instructions to stick out her tongue, deep tendon reflexes are unimpaired and symmetrical, with no signs of hyperreflexia or hyporeflexia,
Musculoskeletal: No joint deformities or effusions appreciated. A full range of motion is present in all joints without pain. Muscle strength in all extremities is sufficient, and no limp or shortened strides noted
Derm: Skin is intact without any rashes, lesions, or ulcers. No signs of trauma or abuse were noted.
Psychosocial: The patient is aware of time, place and person, she is cooperative and engaged during the exam. No evidence of cognitive or mood disturbance. No suicidal or homicidal ideation was noted.
Misc. No additional procedures performed.
Mental Status Exam
Appearance: The patient appears well-groomed and dressed appropriately for the weather and occasion. There are no signs of distress, agitation, or unusual posturing.
Behavior: The patient is cooperative and demonstrates appropriate social skills. There are no signs of hyperactivity, catatonia, or psychomotor retardation.
Speech: The patient speaks clearly and coherently, with a normal rate and tone. No slurring or stuttering is observed.
Mood: The patient appears to be in a euthymic mood state, with no signs of depression or mania.
Affect: The patient’s affect is appropriate to the context of the conversation. There are no signs of flat affect, blunted affect, or inappropriate affect.
Thought Content: The patient denies any delusions or hallucinations. There are no signs of suicidal or homicidal ideation.
Thought Process: The patient’s thought process appears to be goal-directed and logical. No evidence of flight of ideas, tangential thinking, or looseness of associations is observed.
Cognition/Intelligence: The patient demonstrates normal intellectual functioning, with intact attention, concentration, and memory.
Clinical Insight: The patient demonstrates a good understanding of her illness and treatment plan. She is aware of her mood fluctuations and is compliant with her medication regimen.
Clinical Judgment: The patient can make appropriate decisions regarding her treatment and daily life activities. She is aware of her limitations and seeks help when necessary.

Plan:
The Bipolar Spectrum Diagnostic Scale (BSDS).
The Bipolar Spectrum Diagnostic Scale (BSDS) is a self-administered screening tool designed to help identify individuals who may be at risk of bipolar disorder (Bart et al., 2021). The BSDS questions ask about symptoms commonly associated with bipolar disorder, such as changes in mood, energy, and activity level. The patient’s score of 22 indicated a positive for bipolar 1 disorder.
Magnetic Resonance Imaging
Magnetic resonance imaging was conducted to rule out a brain tumor that might be causing the symptoms of the patient. Conventional T1-weighted, T2-weighted, and FLAIR sequences were used in different planes during the brain MRI, with no contrast enhancement. The imaging results show no sign of a tumor, edema, or unusual enhancement. Acute ischemia or inflammatory processes are not supported by any indication of limited diffusion. Both the ventricles and the sulci seem within normal bounds. The cerebellum and brainstem seem healthy. The main cerebral veins seem to be healthy. The results of the imaging test most strongly support the absence of a brain tumor.
The DSM-5 Criteria
Mental health providers can identify bipolar 1 disorder using the standardized diagnostic criteria provided by the DSM-5. The criteria help ensure that people with bipolar 1 disorder are correctly diagnosed and distinguished from other mental disorders that may have similar symptoms by requiring the presence of at least one manic episode, a major depressive episode, and impairments in social, occupational, or other areas of functioning.
Differential Diagnoses
1. Bipolar I Disorder DSM-5 code F31 (ICD-10 code F31.0).
2 Major Depressive Disorder DSM-5 code F32. (ICD-10 code F32.0).
A major depressive episode or episodes constitute Major Depressive Disorder (MDD), a mental illness (Dwyer et al., 2020). The symptoms of a major depressive episode include low mood, loss of interest in or enjoyment of activities, changes in appetite or weight, insomnia or hypersomnia, psychomotor agitation or retardation, fatigue or loss of energy, feelings of worthlessness or excessive guilt, trouble concentrating, and recurrent thoughts of death or suicide. Because both conditions feature depressive periods, MDD and Bipolar 1 Disorder can be confused (Dwyer et al., 2020). However, those with MDD exclusively experience depressive periods, while those with Bipolar 1 Disorder experience both manic and depressed episodes.
Principal Diagnoses
1. Bipolar I Disorder DSM-5 code F31 (ICD-10 code F31.0).
Bipolar 1 disorder is characterized by manic or mixed episodes and depressed phases (Rhee et al., 2020). A manic episode is characterized by an excessively high or irritated mood that lasts for at least a week and may involve symptoms like increased energy, a reduced need for sleep, racing thoughts, grandiosity, or risky behavior. A mixed episode occurs when a person has both manic and depressed symptoms at the same time (Rhee et al., 2020). Symptoms of a depressive episode include low mood, loss of interest in or enjoyment from activities, changes in appetite or weight, hypersomnia or sleeplessness, psychomotor agitation or retardation, feelings of worthlessness, and recurring thoughts of suicide or death.
Plan:
As a mood stabilizer, lithium was prescribed to the patient. Lithium 300 milligrams per day, split into two oral doses taken orally, was the recommended dosage for the patient. A supply of 100 lithium oral capsules with a dosage of 300 mg costs about $15. The patient was advised to drink plenty of fluids because lithium can interfere with the body’s capacity to control fluid balance, leading to dehydration. The patient was instructed to try to consume eight glasses or more of water or other liquids per day.
Diagnosis #1 Bipolar 1 Disorder
Diagnostic Testing/Screening: The Bipolar Spectrum Diagnostic Scale (BSDS). Score of 22
Pharmacological Treatment:
Name: Lithium
Dosage: 300 mg
Route: Taken orally
Frequency: two oral doses each day (morning and bedtime).
Estimated Cost: A supply of 100 lithium oral capsules with a dosage of 300 mg costs about $15.
Non-Pharmacological Treatment: Cognitive behavioral therapy.
Patient/Family Education:
1 Show up for your follow-up and routine appointments with the mental health professional.
2. Follow your doctor’s instructions for taking your medication.
3. Acquire coping mechanisms to control your emotions and actions.
4. To lessen stress, use mindfulness and relaxation practices.
5. Avoid alcohol and drugs because they can make your symptoms worse.
6. Have a nutritious diet that is well-balanced to promote your general health.
Referrals: Psychotherapist for CBT
Follow-up: 1 week to assess symptoms have lessened.
Anticipatory Guidance:
1. Exercise frequently to improve your physical and mental health.
2. Use proper sleep hygiene to ensure restful sleep.
3. Refrain from self-harming actions and seek assistance if you have suicidal or self-harming thoughts.
4. Have reasonable objectives and make progress toward them over time.
5. Analyze the causes of your symptoms and create coping mechanisms.
6. Surround yourself with supportive friends and family.

Signature (with appropriate credentials): __________________________________________

Cite current evidenced based guideline(s) used to guide care (Mandatory)_______________
References
Bart, C. P., Titone, M. K., Ng, T. H., Nusslock, R., & Alloy, L. B. (2021). Neural reward circuit dysfunction as a risk factor for bipolar spectrum disorders and substance use disorders: A review and integration. Clinical Psychology Review, 87, 102035. https://doi.org/10.1016/j.cpr.2021.102035
Dwyer, J. B., Aftab, A., Radhakrishnan, R., Widge, A., Rodriguez, C. I., Carpenter, L. L., … & Ace homework tutors – APA council of the research task force on novel biomarkers and treatments. (2020). Hormonal treatments for major depressive disorder: State of the art. American Journal of Psychiatry, 177(8), 686-705. https://doi.org/10.1176/appi.ajp.2020.19080848
Rhee, T. G., Olfson, M., Nierenberg, A. A., & Wilkinson, S. T. (2020). 20-year trends in the pharmacologic treatment of bipolar disorder by psychiatrists in outpatient care settings. American Journal of Psychiatry, 177(8), 706-715. https://doi.org/10.1176/appi.ajp.2020.19091000

DEA#: 101010101 STU Clinic LIC# 10000000

Tel: (000) 555-1234 FAX: (000) 555-12222

Patient Name: (Initials)________________P.S.______________ Age _____23______
Date: ________20/04/2023_______
RX ________ Lithium ______________________________
SIG: Lithium 300 milligrams per day, split into two oral doses taken orally in the morning and bedtime. A supply of 100 lithium oral capsules with a dosage of 300 mg costs about $15.

Dispense: ____100 tablets_______ Refill: _____0____________
No Substitution
Signature: ____________________________________________________________

+++++++++
Psychotherapy Note:

Session Date: 20/04/2023_____________
Patient Initials: P.S._ Age: 23 Gender: Female_

Presenting Problems:
The patient reported experiencing extreme mood swings over the past two months, with episodes of elevated mood and energy, during which she feels on top of the world, has increased self-confidence, and is very talkative. During these episodes, she feels like she can accomplish anything and that nothing can stop her. These episodes typically last for 5-7 days. The patient also experiences episodes of depression, during which she feels sad, hopeless, and worthless. During these episodes, she has difficulty sleeping, loses interest in activities she used to enjoy, and has trouble concentrating. These episodes typically last for 2-3 weeks. The patient admitted that she has been going through these mood swings for the past two months and that they are making it difficult for her to operate in both her personal and professional lives. She admitted that she is unable to foresee when the episodes will happen and that they tend to start unexpectedly. She admits that she has not felt any respite from her symptoms and that they are getting worse. The patient admitted that stress seems to trigger her episodes, but she also experiences mood swings without any identifiable trigger.

Mental Status Examination:
The patient appeared cooperative and engaged during the session. She was dressed appropriately and maintained eye contact throughout the session. The patient was alert and oriented to person, place, and time. Her speech was clear and coherent, and her thought process was goal-directed. The patient’s mood was depressed and anxious during the session, and her affect was congruent with her mood. She denied any current suicidal ideation or plan but admitted having infrequent suicidal thoughts while suffering from depression episodes in the past. The patient’s cognitive function appeared intact, and she was able to recall both remote and recent memories without difficulty.

Treatment Plan:
The patient will be referred to a psychiatrist for a comprehensive psychiatric evaluation and medication management. She will be educated on the symptoms and management of bipolar disorder and mood disorders. The patient will be advised to keep a mood diary to monitor her mood swings and identify triggers. She will be encouraged to engage in regular physical exercise, mindfulness, and relaxation techniques. The patient will also be referred for psychotherapy to address her emotional dysregulation and coping skills. The therapy will be aimed at improving her emotion regulation skills, increasing her awareness of triggers, and enhancing her coping skills. The patient will be scheduled for follow-up visits to monitor her progress and adjust the treatment plan as needed.

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