Comprehensive Psychiatric Evaluation

Comprehensive Psychiatric Evaluation Template
With Psychotherapy Note
Your Name
Subject and Section
Professor’s Name
Date
Encounter date: April 5, 2022
Patient Initials: L.R. Gender: Female Age: 27 years old Race: Filipino Ethnicity: Bicolano
Reason for Seeking Health Care: “I lost the love of my life, and I do not want to live anymore in a world like this.”
HPI: 6 months prior to consultation, the patient’s fiancé died. The two were riding a motorcycle when suddenly a large truck smashed onto them, resulting in a significant impact. When the patient woke up, they were pierced together by sharp metal but still alive. When the rescuers came, they cut the metal into two and were transferred to the hospital. However, upon arrival, the fiancé already had massive bleeding and bled to death while the patient watched in the emergency room. The patient could not talk to him as he gradually lost his life and thought that it was her fault because they would not have had that accident if she did not ask him to drive her to relieve her stress from work. Because of this, she lost the will to live and immediately wanted to die. However, her fiancé’s family told her that the fiancé would want her to live a life worth living. Initially, the patient wanted to die like he did and had multiple suicidal attempts. She refused to go to the psychiatrist for consultation and wanted to stay at her apartment the whole time. However, the patient tried to follow the will of his fiancé to try to live her life. Thus, she tried hard to eat, sleep, do recreational activities, and go to work.
Interim history revealed that the patient gradually lost her appetite, only eating a meal in small amounts once or twice a day. She also focused on work and refused to talk to or go out with her family and friends. She could not sleep properly and only had 3 to 4 hours of sleep daily, and during weekends, she was asleep for almost 18 hours a day. Due to this, she lost 25 kilograms in five months without attempting to reduce weight. She also claimed to have recurrent thoughts of death, wanting to be with her fiancé in the afterlife.
One month before the consultation, the patient resigned from her work and found a virtual assistant job online where she could work from home. However, after two weeks, she resigned because she could not concentrate on her work and had difficulty analyzing data. The other symptoms were persistent.
A few hours before consultation, the patient was brought to the emergency room for a suicidal attempt via hanging, and a suicide note was found beside her bed.
SI/HI: The patient had persistent suicidal ideations for six months but only had a suicide attempt a few hours before the consultation. No homicidal ideations were noted.
Sleep:  The patient sleeps 3 to 4 hours daily during weekdays and sleeps for 18 hours during weekends.  Appetite: Currently, the patient only eats one or two meals a day in small amounts and sometimes, no meal at all because she does not have an appetite despite ordering her favorite foods.
Allergies (Drug/Food/Latex/Environmental/Herbal): There are no known allergies to drugs, food, latex, environment, or herbal medications.Current perception of Health: Fair
Psychiatric History:
Inpatient hospitalizations:
Date

Hospital

Diagnoses

Length of Stay

None

Not applicable

Not applicable

Not applicable

Outpatient psychiatric treatment:
Date

Hospital

Diagnoses

Length of Stay

None

Not applicable

Not applicable

Not applicable

Detox/Inpatient substance treatment:
Date

Hospital

Diagnoses

Length of Stay

None

Not applicable

Not applicable

Not applicable

History of suicide attempts and self-injurious behaviors: There were no known self-injurious behaviors previously, but the patient had a suicidal attempt via hanging a few hours prior to admission.
Past Medical History
* Major/Chronic Illnesses: None
* Trauma/Injury: The patient had a penetrating injury over the large intestines and a complete fracture, left, on November 3, 2021, after a vehicular motor accident, status-post exploratory laparotomy with J.P. drain placement; closed reduction internal fixation, left femur, under general endotracheal anesthesia. The patient recovered with no complications after two weeks of hospitalization.
* Hospitalizations: No other previous hospitalizations.
Past Surgical History: November 3, 2021: Status-post exploratory laparotomy with J.P. drain placement; closed reduction internal fixation, left femur under general endotracheal anesthesia.
Current psychotropic medications: None
Current prescription medications: None
OTC/Nutritionals/Herbal/Complementary therapy: None
Substance use: (alcohol, marijuana, cocaine, caffeine, cigarettes): The patient is a non-smoker, non-alcoholic beverage drinker, and does not take illicit drugs.
Substance

Amount

Frequency

Length of Use

Caffeine

1 cup (8 ounces)

QID

2015-2022

Family Medical History: There is a history of type 2 diabetes mellitus, hypertension, and rectal cancer on both the mother and father’s sides, with no known history of cerebrovascular and coronary artery disease.
Family Psychiatric History: The patient’s mother, father, and four younger siblings have not been diagnosed with major depressive disorder, bipolar disorder, other mood disorders, or genetic disorders and do not have any history of suicidal attempts or ideations.
Social History
Lives: Alone in a studio apartment on the second floor, the building has stairs and elevators. Marital Status: Single Education: Bachelor of Science in Accountancy
Employment Status: Unemployed Current/Previous occupation type: Previously worked as a full-time employee as a bank teller for two years, then worked as a virtual assistant for two years.
Exposure to: The patient had no exposure to smoking, alcoholic beverages, or recreational drug use.
Sexual Orientation: Heterosexual Sexual Activity: Inactive Contraception Use: None
Family Composition: Family/Mother/Father/Alone: The patient’s parents are presently well. The mother is 53 years old, while the father is 52. The patient is the eldest among five siblings. She had three younger brothers, ages 26, 24, and 22, and a younger sister, age 20.
Other: (Place of birth, childhood hx, legal, living situations, hobbies, abuse hx, trauma, violence, social network, marital hx): The patient was born in Legazpi, Albay, and her family stays in the Philippines. Her childhood history reveals that they had a happy family with strong relationships, and she did not experience or witness any violence from childhood to adulthood. She does not have any pending or active legal issues. She currently lives alone in her apartment. Her hobbies include singing, dancing, and reading novels. There was no history of abuse, trauma, or violence. She has a girl best friend from the Philippines and a small social circle. She was never married before, and she only had one fiancé.
Health Maintenance
Screening Tests (submit with SOAP note): Depression, Anxiety, ADHD, Autism, Psychosis, Dementia: No laboratory or diagnostic tests were reviewed.
Exposures: She was not exposed to occupational hazards, radiation, or illicit drugs.
Immunization H.X.: The patient claimed that she had complete immunization from birth but failed to provide her baby book. She was also vaccinated against COVID-19 (Pfizer) with three doses.
Review of Systems (at least three areas per system):
General: admits to a weight loss from 55 to 40 kilograms in 5 months, feeling of exhaustion most times of the day; denies fever, fainting, or loss of consciousness
HEENT: denies headache, eye pain, bulging of eyes, tinnitus, loss of smell, dysphagia, loss of taste, dental problems, or thyroid enlargement.
Neck: Denies cervical lymph node enlargement and tenderness, and stiff neck
Lungs: Denies cough, wheezing, or difficulty of breathing
Cardiovascular: Admits to easy fatigability but denies chest pain, fainting, or palpitations
Breast: Denies changes in breast skin, foul-smelling nipple discharges, or palpable masses
G.I.: Denies abdominal pain, diarrhea, or constipation
Female genital: Denies dyspareunia, itchiness, or vaginal discharges
GU: Denies dysuria, frequency, or dribbling
Neuro: Admits to persistent low moods but denies changes in sensorium, tingling sensation, or loss of balance
Musculoskeletal: Denies muscle weakness, limitation of motion,
Activity & Exercise: Denies doing any physical or recreational activities.
Psychosocial: Denies going out with friends, talking to family and friends, or talking to workmates
Derm: Denies cold or hot weather intolerance, itchiness, or open wounds
Nutrition: Admits to eating only 2 to 3 spoons of rice and viand per meal, with loss of appetite, and denies use of any nutritional or herbal supplements
Sleep/Rest: Admits to sleep disturbances and feeling tired after long sleeping hours but denies inability to sleep
LMP: March 20, 2022
STI Hx: Denies history of gonorrheal, chlamydial, or HIV infection; admits to occasional bacterial vaginosis
Physical Exam