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Topic:
Reason for Seeking Health Care
Essay Instructions:
//Patient must have an addiction, this is for a PMHNP clinical class of Special Population, The clinical site is in a clinic(Not a hospital).
For this assignment, students will create a written comprehensive psychiatric evaluation of a patient they have seen in the clinic. Your preceptor must sign their initials on this document to confirm they have reviewed and acknowledge this patient was seen in their clinic. Each student will use the Graduate Psychotherapy Note Template.docx to create a detailed psychiatric evaluation document. SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. The comprehensive psychiatric evaluation is to be written using the attached template below.
S.O.A.P. Table S - Subjective data: Patient’s Chief Complaint (CC); History of the Present Illness (HPI)/ Demographics; History of the Present Illness (HPI) (Links to an external site.) that includes the presenting problem and the 8 dimensions of the problem (OLDCARTS); Review of Systems (ROS).
O - Objective data: Medications; Allergies; Past medical history; Family history; Past surgical history; Psychiatric history, Social history; Labs and screening tools; Vital signs; Physical exam, (Focused), and Mental Status Exam.
A - Assessment: Primary Diagnosis and two differential diagnoses including IDC-10 and DSM5 codes.
P - Plan: Pharmacologic and Nonpharmacologic treatment plan; diagnostic testing/screening tools, patient/family teaching, referral, and follow-up.
Other: Incorporate current clinical guidelines NIH Clinical Guidelines (Links to an external site.) or APA Clinical Guidelines (Links to an external site.), research articles, and the role of the PMHNP in your presentation.
Reminder: It is important that you complete this assessment using your critical thinking skills. You are expected to synthesize your clinical assessment, formulate a psychiatric diagnosis, and develop a treatment plan independently. It is not acceptable to document "my preceptor made this diagnosis." An example of the appropriate descriptors of the clinical evaluation is listed below. It is not acceptable to document “within normal limits.”
Graduate Mental Status Exam Guide - Comprehensive Psychotherapy Evaluation.docx Download Graduate Mental Status Exam Guide - Comprehensive Psychotherapy Evaluation.docx
Graduate Psychiatric Note Template
Essay Sample Content Preview:
Reason for Seeking Health Care
Patient Initials: J S Gender: M/F/Transgender M Age: 29 years Race: White Ethnicity: German
Reason for Seeking Health Care: The patient admitted to “experiencing regular upsetting thoughts” and “feeling like I am not in control of my actions.” His anxiety and restlessness were interfering with his relationships and work. The patient informed me: “I am seeking help because I fear I might hurt myself or my sister.”
HPI: John is a 29-year-old white male who has been struggling with mental health issues after getting into a serious car accident that left his wife and daughter died five months ago. The patient states that he has “not been acting like himself” since the accident. He confesses that he has “trouble believing it really happened” and feels especially guilty for being behind the steering wheel. He remembers arguing with his wife as they were returning from her parents-in-law: he does not recall what they were arguing about, but he does remember turning to his wife before they were t-boned by a speeding dumper truck. The patient has recurrent flashbacks of “the car launching sideways into the air and rolling several times before I passed out”. He later woke up in a hospital bed where the bad news was broken to him: “my dear wife and child were dead, they didn’t survive the trip to the hospital.” The patient has since been having uncontrollable thoughts about the accident: a week after the event, he resumed drinking and smoking marijuana (he had managed to stay clean for 18 months after his wife insisted that he seek treatment for his concurrent alcohol and marijuana abuse). He attributed returning to his “old ways” as a means of coping with the constant intrusive thoughts and distressing dreams of his family dying. He reported that after the accident, “I couldn’t hold it anymore, I can’t live with my thoughts. I knew drinking would not bring back my family. I have to get ‘high’, man, to wake up in the morning and go to work, I just have to be ‘high’”. He admitted to immersing himself in work immediately after the funeral without allowing himself enough time to mourn: “I kept myself busy to keep ‘bad’ thoughts away. I am also behind on several business loans I took last year”. He was either at work, at home, or at the bar, but mostly he kept to himself: “I just wanted to be alone. I snap at anyone around me. I am not in control of my emotions and find myself being insensitive to my workmates and parents in law nearly every time. Everyone was understanding at first, but I feel like they are tiring of me”. He does not report having any other social support except his twin sister. She lives in the same area and is credited with being patient with him, even helping with the housework. She has been driving him to work every morning: “I became fearful of driving, and my twin sister picks me up to work. I take the bus home in the evening”. His sister advised him to see a mental health specialist after he admitted to feeling guilty about surviving the accident. The patient did not have any history of mental health illness, and he felt “quite fine” at the time. His clinician, “an old buddy from my high school football days,” chalked it down to an adjustment disorder and advised him to join a support group: the patient confesses to disclosing a few of his symptoms to save face. He was given medications for anxiety, insomnia, and depression, although his substance abuse continued, something he stated contributed to him sometimes not taking the medications as directed. Over the past month, the patient confesses to having flashbacks of the accident, especially images of his dead wife and daughter at the open casket funeral, occurring to him with greater regularity and vividness. These thoughts were now accompanied by physical sensations, including nausea, sweating, chest pains, and trembling: “My heart is constantly racing, and I fear crossing the road. I feel like nowhere is safe and I have to watch my surroundings carefully”. The patient also reported losing his appetite and having recurrent nightmares of getting knocked over by a yellow school bus driven by his wife: “I feel suicidal, but I have not yet managed to act on my ideations. I feel nobody understands what I am going through every day, even my sister. Death is peaceful, and I would like to see my family again.” John reports that his symptoms have worsened in recent times and that he is not sure if he can hold it anymore.
SI/HI: The patient reports having vague ideas about jumping in front of a moving school bus but has not yet fully formulated a plan or found an opportunity to do so: “I am frightened about what this would do to my sister. It’s only her and me now”.
Sleep: The patient reports experiencing insomnia, nightmares, and delayed circadian phase. He confesses that he does not feel like he needs much rest though.
Appetite: The patient admits to having a poor appetite and having lost thirty pounds since the accident.
Allergies (Drug/Food/Latex/Environmental/Herbal): The patient has a severe allergic reaction to latex and latex allergy foods: he is highly sensitive to latex products and such fruits as kiwi, avocado, banana, chestnut, melon, and papaya. He is also mildly allergic to pollen, animal dander, and household chemicals: he describes having rashes, a runny nose, and watery eyes after coming into contact with these substances.
Current perception of Health: Excellent Good Fair Poor
Psychiatric History:
Inpatient hospitalizations:
Date
Hospital
Diagnoses
Length of Stay
Outpatient psychiatric treatment:
Date
Hospital
Diagnoses
Length of Stay
April 20th 2022
Manhattan Mental Health Counseling, New York
Adjustment disorder with depressed mood, disturbance of emotions, and anxiety.
2 months
Detox/Inpatient substance treatment:
Date
Hospital
Diagnoses
Length of Stay
September 5th 2019
New York Center for Living
Alcohol and marijuana use disorder
3 months
History of suicide attempts and/or self injurious behaviors: The patient has not had any history of suicide attempts and/or self injurious behaviors
Past Medical History
* Major/Chronic Illnesses: Diagnosed with allergic asthma at 10 years old (current).
* Trauma/Injury: Treated for a broken arm six years ago and for neck strain, head bruises, and a broken hip from the car accident (active).
* Hospitalizations: Hospitalized for anaphylaxis in 2005 after mistakenly eating chestnut at a party, for an appendectomy in 2007, for a broken arm sustained during a football game in 2016, and in 2022 after the car accident.
Past Surgical History: The patient had an emergency surgery in 2005 for a complicated acute appendicitis. He also underwent surgery to stabilize his arm and hip fractures in 2016 and 2022 respectively.
Current psychotropic medications:
Antidepressants, anti-anxiety medications, and mood stabilizers
Current prescription medications:
Zoloft delivered orally at 50 mg per day; Ativan delivered orally at 2 mg two times per day; and Alprazolam at 1.5 mg/day.
OTC/Nutritionals/Herbal/Complementary therapy:
_________________________________________________________________________
_________________________________________________________________________
Substance use: (alcohol, marijuana, cocaine, caffeine, cigarettes)
Substance
Amount
Frequency
Length of Use
Alcohol
6 drinks per day
Daily
5 months
Marijuana
7 joints a day
Daily
5 months
Family Psychiatric History: The patient reports that both his grandfathers as well as his father had a history of bipolar depression and were hospitalized several times for the mental disorder. His elder brother, an Iraq veteran, suffered from PTSD and committed suicide two years after returning from tour. The patient’s mother passed away shortly after he and his sister were born. However, he does remember hearing his elder brother once mentioning that she had anxiety issues. Her sister suffers from the same social anxiety issues, although she is doing quite well now after seeking therapy. Family psychiatric history is otherwise negative. There is no other history of psychiatric disorder, hospitalization, or suicidal behaviors.
Social History
Lives: Single family House/Condo/ with stairs: The patient lives alone in a single-family house with stairs in Jamesville, New York. Marital Status: Single
Education: College
Employment Status: Full-time Employed Current/Previous occupation type: Construction site supervisor
Exposure to: Smoke: Yes ETOH: Yes Recreational Drug Use: Yes
Sexual Orientation: Heterosexual Sexual Activity: The client reports being sexually inactive since his family’s death Contraception Use: ____________
Family Composition: Family/Mother/Father/Alone: The patient has a twin sister, who is the only surviving member of the family. His father and elder brother passed away in his early adulthood years. His mother passed away shortly after child birth.
Other: (Place of birth, childhood hx, legal, living situations, hobbies, abuse hx, trauma, violence, social network, marital hx): The patient describes his early childhood memories at his grandparent’s farm in Utah as the happiest, even though he had emotional problems accepting his mother’s death and absence. However, he fondly remembers his elder brother stepping in as a guardian whenever their father was absent at work: his sister was particularly devastated when he passed away. His father never married and started showing signs of manic depression shortly after the family moved to New York, he was 15 at that time. He describes his father as “stern”, “demanding”, and “distant” although he later came to understand and forgive him for his “indifference”. The patient has had challenges keeping friends since childhood and cites his sister and deceased family as the only reliable social networks he had after the death of his brother. He describes his relationship with his workmates as friendly but “formal” although he has been invited at several family dinners by his boss. The patient acknowledges that he had a happy marriage: his wife was his first love and they married while he was still in college. He describes his wife and daughter as the “loves of his life” and is unsure how he is supposed to live without them.
Health Maintenance
Screening Tests (submit with SOAP note): Depression, Anxiety, ADHD, Autism, Psychosis, Dementia
Subjective: The patient is a 29-year-old white male who reports of recurrent, upsetting memories of the deaths of his wife and daughter in a car accident that occurred five months ago. These vivid flashbacks of the traumatic event are accompanied by unwanted nightmares of his wife running him over at a bus stop, a dream that is tied to his recent suicidal ideations. He has tried to drown his feelings by immersing himself in work, resuming his daily use of alcohol and marijuana, evading his in-laws, as well as avoiding all social activities, neighbors, and workmates. He feels guilty about surviving the accident and is finding it increasingly difficult to maintain close relationships: “I am always in a foul mood and find it impossible to enjoy anything. I am aggressive to everyone even when there is no need to”. He is afraid of driving and is always on the lookout for a road hazard. These symptoms have intensified over the past month and he feels that he does not trust himself anymore, even when he is around his sister, who he credits for “trying to make...
Patient Initials: J S Gender: M/F/Transgender M Age: 29 years Race: White Ethnicity: German
Reason for Seeking Health Care: The patient admitted to “experiencing regular upsetting thoughts” and “feeling like I am not in control of my actions.” His anxiety and restlessness were interfering with his relationships and work. The patient informed me: “I am seeking help because I fear I might hurt myself or my sister.”
HPI: John is a 29-year-old white male who has been struggling with mental health issues after getting into a serious car accident that left his wife and daughter died five months ago. The patient states that he has “not been acting like himself” since the accident. He confesses that he has “trouble believing it really happened” and feels especially guilty for being behind the steering wheel. He remembers arguing with his wife as they were returning from her parents-in-law: he does not recall what they were arguing about, but he does remember turning to his wife before they were t-boned by a speeding dumper truck. The patient has recurrent flashbacks of “the car launching sideways into the air and rolling several times before I passed out”. He later woke up in a hospital bed where the bad news was broken to him: “my dear wife and child were dead, they didn’t survive the trip to the hospital.” The patient has since been having uncontrollable thoughts about the accident: a week after the event, he resumed drinking and smoking marijuana (he had managed to stay clean for 18 months after his wife insisted that he seek treatment for his concurrent alcohol and marijuana abuse). He attributed returning to his “old ways” as a means of coping with the constant intrusive thoughts and distressing dreams of his family dying. He reported that after the accident, “I couldn’t hold it anymore, I can’t live with my thoughts. I knew drinking would not bring back my family. I have to get ‘high’, man, to wake up in the morning and go to work, I just have to be ‘high’”. He admitted to immersing himself in work immediately after the funeral without allowing himself enough time to mourn: “I kept myself busy to keep ‘bad’ thoughts away. I am also behind on several business loans I took last year”. He was either at work, at home, or at the bar, but mostly he kept to himself: “I just wanted to be alone. I snap at anyone around me. I am not in control of my emotions and find myself being insensitive to my workmates and parents in law nearly every time. Everyone was understanding at first, but I feel like they are tiring of me”. He does not report having any other social support except his twin sister. She lives in the same area and is credited with being patient with him, even helping with the housework. She has been driving him to work every morning: “I became fearful of driving, and my twin sister picks me up to work. I take the bus home in the evening”. His sister advised him to see a mental health specialist after he admitted to feeling guilty about surviving the accident. The patient did not have any history of mental health illness, and he felt “quite fine” at the time. His clinician, “an old buddy from my high school football days,” chalked it down to an adjustment disorder and advised him to join a support group: the patient confesses to disclosing a few of his symptoms to save face. He was given medications for anxiety, insomnia, and depression, although his substance abuse continued, something he stated contributed to him sometimes not taking the medications as directed. Over the past month, the patient confesses to having flashbacks of the accident, especially images of his dead wife and daughter at the open casket funeral, occurring to him with greater regularity and vividness. These thoughts were now accompanied by physical sensations, including nausea, sweating, chest pains, and trembling: “My heart is constantly racing, and I fear crossing the road. I feel like nowhere is safe and I have to watch my surroundings carefully”. The patient also reported losing his appetite and having recurrent nightmares of getting knocked over by a yellow school bus driven by his wife: “I feel suicidal, but I have not yet managed to act on my ideations. I feel nobody understands what I am going through every day, even my sister. Death is peaceful, and I would like to see my family again.” John reports that his symptoms have worsened in recent times and that he is not sure if he can hold it anymore.
SI/HI: The patient reports having vague ideas about jumping in front of a moving school bus but has not yet fully formulated a plan or found an opportunity to do so: “I am frightened about what this would do to my sister. It’s only her and me now”.
Sleep: The patient reports experiencing insomnia, nightmares, and delayed circadian phase. He confesses that he does not feel like he needs much rest though.
Appetite: The patient admits to having a poor appetite and having lost thirty pounds since the accident.
Allergies (Drug/Food/Latex/Environmental/Herbal): The patient has a severe allergic reaction to latex and latex allergy foods: he is highly sensitive to latex products and such fruits as kiwi, avocado, banana, chestnut, melon, and papaya. He is also mildly allergic to pollen, animal dander, and household chemicals: he describes having rashes, a runny nose, and watery eyes after coming into contact with these substances.
Current perception of Health: Excellent Good Fair Poor
Psychiatric History:
Inpatient hospitalizations:
Date
Hospital
Diagnoses
Length of Stay
Outpatient psychiatric treatment:
Date
Hospital
Diagnoses
Length of Stay
April 20th 2022
Manhattan Mental Health Counseling, New York
Adjustment disorder with depressed mood, disturbance of emotions, and anxiety.
2 months
Detox/Inpatient substance treatment:
Date
Hospital
Diagnoses
Length of Stay
September 5th 2019
New York Center for Living
Alcohol and marijuana use disorder
3 months
History of suicide attempts and/or self injurious behaviors: The patient has not had any history of suicide attempts and/or self injurious behaviors
Past Medical History
* Major/Chronic Illnesses: Diagnosed with allergic asthma at 10 years old (current).
* Trauma/Injury: Treated for a broken arm six years ago and for neck strain, head bruises, and a broken hip from the car accident (active).
* Hospitalizations: Hospitalized for anaphylaxis in 2005 after mistakenly eating chestnut at a party, for an appendectomy in 2007, for a broken arm sustained during a football game in 2016, and in 2022 after the car accident.
Past Surgical History: The patient had an emergency surgery in 2005 for a complicated acute appendicitis. He also underwent surgery to stabilize his arm and hip fractures in 2016 and 2022 respectively.
Current psychotropic medications:
Antidepressants, anti-anxiety medications, and mood stabilizers
Current prescription medications:
Zoloft delivered orally at 50 mg per day; Ativan delivered orally at 2 mg two times per day; and Alprazolam at 1.5 mg/day.
OTC/Nutritionals/Herbal/Complementary therapy:
_________________________________________________________________________
_________________________________________________________________________
Substance use: (alcohol, marijuana, cocaine, caffeine, cigarettes)
Substance
Amount
Frequency
Length of Use
Alcohol
6 drinks per day
Daily
5 months
Marijuana
7 joints a day
Daily
5 months
Family Psychiatric History: The patient reports that both his grandfathers as well as his father had a history of bipolar depression and were hospitalized several times for the mental disorder. His elder brother, an Iraq veteran, suffered from PTSD and committed suicide two years after returning from tour. The patient’s mother passed away shortly after he and his sister were born. However, he does remember hearing his elder brother once mentioning that she had anxiety issues. Her sister suffers from the same social anxiety issues, although she is doing quite well now after seeking therapy. Family psychiatric history is otherwise negative. There is no other history of psychiatric disorder, hospitalization, or suicidal behaviors.
Social History
Lives: Single family House/Condo/ with stairs: The patient lives alone in a single-family house with stairs in Jamesville, New York. Marital Status: Single
Education: College
Employment Status: Full-time Employed Current/Previous occupation type: Construction site supervisor
Exposure to: Smoke: Yes ETOH: Yes Recreational Drug Use: Yes
Sexual Orientation: Heterosexual Sexual Activity: The client reports being sexually inactive since his family’s death Contraception Use: ____________
Family Composition: Family/Mother/Father/Alone: The patient has a twin sister, who is the only surviving member of the family. His father and elder brother passed away in his early adulthood years. His mother passed away shortly after child birth.
Other: (Place of birth, childhood hx, legal, living situations, hobbies, abuse hx, trauma, violence, social network, marital hx): The patient describes his early childhood memories at his grandparent’s farm in Utah as the happiest, even though he had emotional problems accepting his mother’s death and absence. However, he fondly remembers his elder brother stepping in as a guardian whenever their father was absent at work: his sister was particularly devastated when he passed away. His father never married and started showing signs of manic depression shortly after the family moved to New York, he was 15 at that time. He describes his father as “stern”, “demanding”, and “distant” although he later came to understand and forgive him for his “indifference”. The patient has had challenges keeping friends since childhood and cites his sister and deceased family as the only reliable social networks he had after the death of his brother. He describes his relationship with his workmates as friendly but “formal” although he has been invited at several family dinners by his boss. The patient acknowledges that he had a happy marriage: his wife was his first love and they married while he was still in college. He describes his wife and daughter as the “loves of his life” and is unsure how he is supposed to live without them.
Health Maintenance
Screening Tests (submit with SOAP note): Depression, Anxiety, ADHD, Autism, Psychosis, Dementia
Subjective: The patient is a 29-year-old white male who reports of recurrent, upsetting memories of the deaths of his wife and daughter in a car accident that occurred five months ago. These vivid flashbacks of the traumatic event are accompanied by unwanted nightmares of his wife running him over at a bus stop, a dream that is tied to his recent suicidal ideations. He has tried to drown his feelings by immersing himself in work, resuming his daily use of alcohol and marijuana, evading his in-laws, as well as avoiding all social activities, neighbors, and workmates. He feels guilty about surviving the accident and is finding it increasingly difficult to maintain close relationships: “I am always in a foul mood and find it impossible to enjoy anything. I am aggressive to everyone even when there is no need to”. He is afraid of driving and is always on the lookout for a road hazard. These symptoms have intensified over the past month and he feels that he does not trust himself anymore, even when he is around his sister, who he credits for “trying to make...
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