Case Study Name: Mrs. Leslie Tilman Gender: female Age: 32 years old T- 97.6 P- 97 R 22 149/98 Ht 5’3 Wt 245lbs Background: Recently had her first child tw
Case Study Name: Mrs. Leslie Tilman Gender: female Age: 32 years old T- 97.6 P- 97 R 22 149/98 Ht 5’3 Wt 245lbs Background: Recently had her first child two months ago. Currently married; stay at home mother after working in retail for 5 years. Grew up with both parents, one sister in Omaha, NE. Completed education through bachelor’s level, studying physics. Previous employment included research science as well as high school substitute teaching for 5 years prior to birth. No previous suicidal gestures; has uncle who committed suicide via GSW. She denied drugs/alcohol; uncle was opioid abuser. Hx of HTN-prescribed labetalol 100mg twice daily, admits to missing doses due to forgetting. No legal hx. Allergies: codeine
Mrs. Tilman, your husband is extremely worried about you.
MRS. TILMAN Yes, I know that.
Does coming her bother you?
TILMAN Yes. Yes it does. I’ve never been to a shrink before. I don’t think I need to be here now.
I’d like to ask you a few questions if that’s ok.
TILMAN Yeah, that should be fine.
TILMAN I can’t sleep much. But that’s to be expected.
MRS. TILMAN The baby. It cries a lot.
And what wakes you?
MRS. TILMAN Well I’m usually already awake.
\You have trouble sleeping?
MRS. TILMAN Just falling asleep. Especially after the baby cries.
What’s the baby’s name?
Beautiful name. How old is she?
TILMAN Two months.
How has your appetite been lately?
\MRS. TILMAN I don’t know. It’s not big, but I want to lose weight after the pregnancy.
You aren’t comfortable with the way you look?
MRS. TILMAN I’m terrible. Alright. I look terrible, I feel terrible. My body is bloated. I have lines on my face, bags. I look disgusting.
What do you do to lose weight?
MRS. TILMAN Well, I want to run, but… I don’t get out much.
MRS. TILMAN Cause I’m stuck at home. I have to take care of the baby, all day long. I guess I should just get used to it. This is my life now all day long, stuck at home with the kid.
MRS. TILMAN Who could afford one? Especially with having to pay for the kid.
Have you said any of this to your husband?
MRS. TILMAN To Rick?
DR. GREY Uh huh.
MRS. TILMAN No. I couldn’t. He’d be so disappointed in me. How could I even tell him that I felt this way. That I wanted out. He comes home from work and… he plays with Jessica. This perfect family.
How has your relationship been?
MRS. TILMAN Not good.
What’s happened since Jessica was born?
ILMAN It’s not added much. I mean it is my fault. I can’t stop crying. All the time. [she cries] Sometimes I don’t even know who the baby is. And I yell a lot. Things just upset me. Everything and anything he does lately just upsets me.
MRS. TILMAN Well… Well the other day he came home and changed her diaper but he threw the dirty diaper in the wrong trash can and he didn’t tie it up in the bag the way he was supposed to.
And that upset you?
MRS. TILMAN Yeah. And I told him, and I was yelling so he started yelling. So yeah. That’s our marriage right now.
Have you been sexually active since Jessica was born?
MRS. TILMAN No. Not really. I have no drive or desire. Rick keeps wanting to but I just… I push him away.
And how is your social life?
MRS. TILMAN Non-existent. I haven’t seen my friends in forever. They came over to see the baby but that’s about it. I might as well get used to it. I can’t go out anymore. She’s too young for a baby sitter, and even then we couldn’t afford one. I had to quit my job.
Were you forced to quit?
MRS. TILMAN No. They gave me maternity leave, but… but I figured this is never going to end. I might as well leave now.
Do you do anything for yourself? Something to relax, something creative?
MRS. TILMAN No. I tried writing. I liked writing but… I don’t know, I… nothing moves me.
You can’t write now?
MRS. TILMAN I have no inspiration, and it’s not fun. I know I’m going to be interrupted soon anyway. Before Jessica, I could write for hours a night. I hated anyone disturbing me. [she cries] Now I can’t have twenty minutes. And you can’t tell a baby to hold on with wanting her lunch. For an hour. When she’s hungry, she’s hungry.
Do you regret having a child?
MRS. TILMAN No. I… I’m just not sure. I’m not sure, okay.
Are you happy? Does anything give you pleasure?
MRS. TILMAN [Shakes her head] No. [she cries]. Look, please, I… I know I’m a mother now. I. [sigh] I don’t know how to put this, I feel terrible. [Cries harder]. I don’t want to be a bad mother. I love my daughter. But I don’t know… I don’t know why I say these things. It’s just really difficult… and Rick, I see Rick and he has this look. It’s this look, its like I know what you’re thinking. It’s like he’s judging me. It’s like he knows I’m not normal. I mean, what’s wrong with me? Sometimes I can’t even hold my own child, I… I, she’s crying and I can’t… I can’t touch her. And when I give her milk it disgusts me. I don’t know what to do. I don’t know what’s wrong with me. I don’t know what’s wrong with me. [She reaches for a tissue]
Mrs. Tilman, do you have thoughts of suicide or death?
[she shakes her head yes]
Have you acted upon them?
MRS. TILMAN [she shakes her head no] No. I couldn’t. I couldn’t do that to Rick or Jessica. And then I feel guilty again. It’s this… this endless cycle. I’m not happy and I want to get out and if I get out, then I would just… I would just… just ruin everyone and that makes me more unhappy.
NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Exemplar
INSTRUCTIONS ON HOW TO USE EXEMPLAR AND TEMPLATE—READ CAREFULLY
If you are struggling with the format or remembering what to include, follow the Comprehensive Psychiatric Evaluation Template
the Rubric as your guide. It is also helpful to review the rubric in detail in order not to lose points unnecessarily because you missed something required. Below highlights by category are taken directly from the grading rubric for the assignment in Weeks 4–10. After reviewing the full details of the rubric, you can use it as a guide.
In the Subjective section, provide:
· Chief complaint
· History of present illness (HPI)
· Past psychiatric history
· Medication trials and current medications
· Psychotherapy or previous psychiatric diagnosis
· Pertinent substance use, family psychiatric/substance use, social, and medical history
· Read rating descriptions to see the grading standards!
In the Objective section, provide:
· Physical exam documentation of systems pertinent to the chief complaint, HPI, and history
· Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses.
· Read rating descriptions to see the grading standards!
In the Assessment section, provide:
· Results of the mental status examination,
presented in paragraph form.
· At least three differentials with supporting evidence. List them from top priority to least 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
· Read rating descriptions to see the grading standards!
Reflect on this case. Include: Discuss what you learned and what you might do differently. 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.).
(The comprehensive evaluation is typically the initial new patient evaluation. You will practice writing this type of note in this course. You will be ruling out other mental illnesses so often you will write up what symptoms are present and what symptoms are not present from illnesses to demonstrate you have indeed assessed for all illnesses which could be impacting your patient. For example, anxiety symptoms, depressive symptoms, bipolar symptoms, psychosis symptoms, substance use, etc.)
EXEMPLAR BEGINS HERE
CC (chief complaint): A brief statement identifying why the patient is here. This statement is verbatim of the patient’s own words about why presenting for assessment. For a patient with dementia or other cognitive deficits, this statement can be obtained from a family member.
HPI: Begin this section with patient’s initials, age, race, gender, purpose of evaluation, current medication and referral reason. For example:
N.M. is a 34-year-old Asian male presents for psychiatric evaluation for anxiety. He is currently prescribed sertraline which he finds ineffective. His PCP referred him for evaluation and treatment.
P.H., a 16-year-old Hispanic female, presents for psychiatric evaluation for concentration difficulty. She is not currently prescribed psychotropic medications. She is referred by her therapist for medication evaluation and treatment.
Then, this section continues with the symptom analysis for your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis.
Paint a picture of what is wrong with the patient. First what is bringing the patient to your evaluation. Then, include a PSYCHIATRIC REVIEW OF SYMPTOMS. The symptoms onset, duration, frequency, severity, and impact. Your description here will guide your differential diagnoses. You are seeking symptoms that may align with many DSM-5 diagnoses, narrowing to what aligns with diagnostic criteria for mental health and substance use disorders.
Past Psychiatric History: This section documents the patient’s past treatments. Use the mnemonic Go Cha MP.
General Statement: Typically, this is a statement of the patients first treatment experience. For example: The patient entered treatment at the age of 10 with counseling for depression during her parents’ divorce. OR The patient entered treatment for detox at age 26 after abusing alcohol since age 13.
Caregivers are listed if applicable.
Hospitalizations: How many hospitalizations? When and where was last hospitalization? How many detox? How many residential treatments? When and where was last detox/residential treatment? Any history of suicidal or homicidal behaviors? Any history of self-harm behaviors?
Medication trials: What are the previous psychotropic medications the patient has tried and what was their reaction? Effective, Not Effective, Adverse Reaction? Some examples: Haloperidol (dystonic reaction), risperidone (hyperprolactinemia), olanzapine (effective, insurance wouldn’t pay for it)
Psychotherapy or Previous Psychiatric Diagnosis: This section can be completed one of two ways depending on what you want to capture to support the evaluation. First, does the patient know what type? Did they find psychotherapy helpful or not? Why? Second, what are the previous diagnosis for the client noted from previous treatments and other providers. Thirdly, you could document both.
Substance Use History: This section contains any history or current use of caffeine, nicotine, illicit substance (including marijuana), and alcohol. Include the daily amount of use and last known use. Include type of use such as inhales, snorts, IV, etc. Include any histories of withdrawal complications from tremors, Delirium Tremens, or seizures.
Family Psychiatric/Substance Use History: This section contains any family history of psychiatric illness, substance use illnesses, and family suicides. You may choose to use a genogram to depict this information. Be sure to include a reader’s key to your genogram or write up in narrative form.
Social History: This section may be lengthy if completing an evaluation for psychotherapy or shorter if completing an evaluation for psychopharmacology. However, at a minimum, please include:
Where patient was born, who raised the patient
Number of brothers/sisters (what order is the patient within siblings)
Who the patient currently lives with in a home? Are they single, married, divorced, widowed? How many children?
Work History: currently working/profession, disabled, unemployed, retired?
Legal history: past hx, any current issues?
Trauma history: Any childhood or adult history of trauma?
Violence Hx: Concern or issues about safety (personal, home, community, sexual (current & historical)
Medical History: This section contains any illnesses, surgeries, include any hx of seizures, head injuries.
Current Medications: Include dosage, frequency, length of time used, and reason for use. Also include OTC or homeopathic products.
Allergies: Include medication, food, and environmental allergies separately. Provide a description of what the allergy is (e.g., angioedema, anaphylaxis). This will help determine a true reaction vs. intolerance.
Reproductive Hx: Menstrual history (date of LMP), Pregnant (yes or no), Nursing/lactating (yes or no), contraceptive use (method used), types of intercourse: oral, anal, vaginal, other, any sexual concerns
ROS: Cover all body systems that may help you include or rule out a differential diagnosis. Please note: THIS IS DIFFERENT from a physical examination!
You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.
Example of Complete ROS:
GENERAL: No weight loss, fever, chills, weakness, or fatigue.
HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.
RESPIRATORY: No shortness of breath, cough, or sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.
GENITOURINARY: Burning on urination, urgency, hesitancy, odor, odd color
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness.
HEMATOLOGIC: No anemia, bleeding, or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.
Physical exam (If applicable and if you have opportunity to perform—document if exam is completed by PCP): From head to toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head-to-toe format i.e., General: Head: EENT: etc.
Diagnostic results: Include any labs, X-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines).
Mental Status Examination: For the purposes of your courses, this section must be presented in paragraph form and not use of a checklist! This section you will describe the patient’s appearance, attitude, behavior, mood and affect, speech, thought processes, thought content, perceptions (hallucinations, pseudohallucinations, illusions, etc.)., cognition, insight, judgment, and SI/HI. See an example below. You will modify to include the specifics for your patient on the above elements—DO NOT just copy the example. You may use a preceptor’s way of organizing the information if the MSE is in paragraph form.
He is an 8-year-old African American male who looks his stated age. He is cooperative with examiner. He is neatly groomed and clean, dressed appropriately. There is no evidence of any abnormal motor activity. His speech is clear, coherent, normal in volume and tone. His thought process is goal directed and logical. There is no evidence of looseness of association or flight of ideas. His mood is euthymic, and his affect appropriate to his mood. He was smiling at times in an appropriate manner. He denies any auditory or visual hallucinations. There is no evidence of any delusional thinking. He denies any current suicidal or homicidal ideation. Cognitively, he is alert and oriented. His recent and remote memory is intact. His concentration is good. His insight is good.
Differential Diagnoses: You must have at least three differentials with supporting evidence. Explain what rules each differential in or out and justify your primary diagnosis selection. You will use supporting evidence from the literature to support your rationale. Include pertinent positives and pertinent negatives for the specific patient case.
Also included in this section is the reflection. Reflect on this case and discuss whether or not you agree with your preceptor’s assessment and diagnostic impression of the patient and why or why not. What did you learn from this case? What would you do differently?
Also include in your reflection a discussion related to legal/ethical considerations (demonstrating 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.).
References (move to begin on next page)
You are required to include at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines which relate to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting.
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