· GENERAL: 

Parker Baker 28-year-old male in the hospital after a fall. Parker is in graduate school studying microbiology and planning to go to medical school. He drinks beer and vodka every night, even blacking out sometimes. Taylor is his 3-year girlfriend. Parker has serious drinking problems and hangovers often, off-balance at times. As a result of this behavior, he misses school. The school wants to kick him out. When Parker is drunk, he is verbally and physically aggressive. Parker has yellowing of sclera and did not remember that he fell and was being interviewed during his discharge.

Complete and submit your Comprehensive Psychiatric Evaluation, including your differential diagnosis and critical-thinking process to formulate primary diagnosis.

Incorporate the following into your responses in the template:

  • Subjective: What      details did the patient provide regarding their chief complaint and      symptomology to derive your differential diagnosis? What is the duration      and severity of their symptoms? How are their symptoms impacting their      functioning in life?
  • Objective: What      observations did you make during the psychiatric assessment?
  • Assessment: Discuss      the patient’s mental status examination results. What were your      differential diagnoses? Provide a minimum of three possible diagnoses with      supporting evidence, listed in order from highest priority to lowest      priority. Compare the DSM-5 diagnostic criteria for each differential      diagnosis and explain what DSM-5 criteria rules out the differential      diagnosis to find an accurate diagnosis. Explain the critical-thinking      process that led you to the primary diagnosis you selected. Include      pertinent positives and pertinent negatives for the specific patient case.
  • Reflection notes: What      would you do differently with this client if you could conduct the session      over? Also include in your reflection a discussion related to      legal/ethical considerations (demonstrate critical thinking beyond      confidentiality and consent for treatment!), health promotion and disease      prevention taking into consideration patient factors (such as age, ethnic      group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural      background, etc.).

NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template

CC (chief complaint):

HPI:

Past Psychiatric History:

· General Statement:

· Caregivers (if applicable):

· Hospitalizations:

· Medication trials:

· Psychotherapy or Previous Psychiatric Diagnosis:

Substance Current Use and History: 

Family Psychiatric/Substance Use History: 

Psychosocial History: 

Medical History: 

· Current Medications:

· Allergies:

  • Reproductive Hx:

ROS:

· GENERAL:

· HEENT:

· SKIN:

· CARDIOVASCULAR:

· RESPIRATORY:

· GASTROINTESTINAL:

· GENITOURINARY:

· NEUROLOGICAL:

· MUSCULOSKELETAL:

· HEMATOLOGIC:

· LYMPHATICS:

· ENDOCRINOLOGIC:

Physical exam: if applicable

Diagnostic results:

Assessment

Mental Status Examination:

Differential Diagnoses:

Reflections:

References

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