Comprehensive Psychiatric Evaluation

For this Assignment, you will document information about a patient that you examined during the last 3 weeks, using the Comprehensive Psychiatric Evaluation Template provided. You will then use this note to develop and record a case presentation for this patient.
Assignment:
• Select a patient that you examined during the last 3 weeks who presented with a disorder other than the one present in your previous selected case. (Note to Writer: You may use below “Patient” information and create addtl’ information as needed to complete assignment to the fullest.)
• Conduct a Comprehensive Psychiatric Evaluation on this patient using the template provided. There is also a completed exemplar document so that you can see an example of the types of information a completed evaluation document should contain.
• Include chief complaint; history of present illness; any pertinent past psychiatric, substance use, medical, social, family history; most recent mental status exam; and current psychiatric diagnosis, including differentials that were ruled out.
• Include at least five (5) scholarly resources to support your assessment and diagnostic reasoning.

Patient:
43yo Hispanic Female
Dx:

• Severe Depressive Disorder with psychotic features
• Generalized Anxiety d/o
• PTSD
• Insomnia
• Hallucination

Medications:

• Risperdal 0.5mg BID
• Wellbutrin/ Bupropion 100mg BID
• Trazadone 50mg HS PRN

Patient had been previously diagnosed with schizophrenia about 20+years ago, but wasn’t hearing voices at that time. History to sexual assault at 5yo by 16yo brother Abandoned by mother at 6mths old Father deceased at 3yo Raised by grandmother who physically abused her Current episodes triggered by anxiety of past Has been hearing voices x2mths Sleeps only about 3hrs a night No history of suicide attempt, positive history of suicidal ideation No known family h/o Mental illness Has been eating a lot Referral to therapist placed Medications sent to pharmacy Follow up in 1 week

Resources to consider:
• Carlat, D. J. (2017). The psychiatric interview (4th ed.). Wolters Kluwer.
o Chapter 31, “Assessing Personality Disorders”
o Chapter 32, “How to Educate Your Patient”
• American Psychiatric Association. (2022). Sexual dysfunctionsLinks to an external site.. In Diagnostic and statistical manual of mental disorders (5th ed., text rev.).

• American Psychiatric Association. (2022). Paraphilic disordersLinks to an external site.. In Diagnostic and statistical manual of mental disorders (5th ed., text rev.).

• Boland, R. Verdiun, M. L. & Ruiz, P. (2022). Kaplan & Sadock’s synopsis of psychiatry (12th ed.). Wolters Kluwer.

NOTE: Please use Resources/References not older than 5-years. (Late 2018/2019 – 2023)