Assessing and Diagnosing Patients With Mood Disorders – Comprehensive Psychiatric Evaluation Template

Subjective:

CC (chief complaint): “I have a bit of a head cold” and desire to go home.

HPI: E.L., an 18-year-old male, presents to the clinic with symptoms of mood dysregulation. He indicated that he was recently hospitalized after having manic-like episodes. He described experiencing symptoms such as inappropriate behavior, not having enough sleep, and increased energy levels. This patient reported feeling “shaky” and “stiff” after taking his current medications. However, he acknowledges experiencing an improvement in his thought process and behavioral control.

Past Psychiatric History:

• General Statement: Mood disorder treatment started at the age of 15
• Caregivers (if applicable): Lives with his two parents
• Hospitalizations: Had a 6-day hospitalization one year ago after he was found wandering in the mall parking lot without clothes
• Medication trials: Risperidone and quetiapine, which were discontinued
• Psychotherapy or Previous Psychiatric Diagnosis: Mood Disorder (likely bipolar disorder)

Substance Current Use and History: The patient denies recent alcohol or substance use. Has no reported substance abuse history.

Family Psychiatric/Substance Use History:

The father has a history of bipolar disorder.

There is no known family history of suicide.  

Psychosocial History:

Resides with parents and sister in Durham, NC

Completed high school

Not currently employed or in school

GET ASSIGNMENT HELP HERE

Not currently partnered

Pending court date for indecent exposure

History of Juvenile Vandalism

Recent behavioral issues include: Sexually inappropriate comments to female neighbors, pulling pants down in the mall, spending excessive money on video games, and attempting to write a book about video game mastery.

Medical History:

• Current Medications: Takes medication 4 times daily with meals and before bed
• Allergies: Latex

• Reproductive Hx: Not sexually driven. Has no reported sexual health concerns.  

 

ROS:

• GENERAL: Denies unintended weight loss, fever, or weakness. Repeated decreased appetite and reduced sleep.
• HEENT: Denies visual loss, blurred vision, hearing loss, sneezing, congestion, runny nose, or sore throat.
• SKIN: Denies having rash or itching.
• CARDIOVASCULAR: Denies chest pain, pressure, or discomfort.
• RESPIRATORY: Denies experiencing shortness of breath, cough, or sputum.
• GASTROINTESTINAL: Ongoing decrease in his oral intake, appetite
• GENITOURINARY: Denies experiencing pain during urination, urgency, hesitancy, or odor.
• NEUROLOGICAL: Reported feeling “shaky “and “stiff”
• MUSCULOSKELETAL: Reports experiencing stiffness, especially during physical activity
• HEMATOLOGIC: Denies anemia, bleeding, or bruising
• LYMPHATICS: Denies having swollen lymph nodes.
• ENDOCRINOLOGIC: Denies experiencing sweating, cold, or heat intolerance.

Objective:

Physical exam:

Vital Signs:

• Temperature: 98.3°F, Pulse: 93 bpm, Respiratory Rate: 22 breaths/min, Blood Pressure: 118/68 mmHg, Height: 5’7″, Weight: 149 lbs
• Appears cooperative and engaged
• Speech more organized compared to initial admission
• Demonstrates insight into previous behavioral changes

Diagnostic results: None provided

Assessment:

Mental Status Examination

The patient is an 18-year-old African American who appears his stated age. He demonstrated a cooperative and engaged demeanor, sitting comfortably and maintaining appropriate eye contact. His general appearance is net and well-groomed, and his clothing is clean and proper for the setting. The patient’s speech is clear and articulate, with a normal volume and tone that depicts improving his mental state. He has a logical thought process. His thoughts are goal-directed. In terms of emotion, the patient’s affect is congruent with his current mood. Cognitively, the patient is alert and fully oriented. His memory appears intact, as evidenced by his ability to recall recent and past events. He has good concentration and can engage in detailed discussions. The patient exhibits a clear understanding of his treatment goals and shows a strong motivation to maintain his mental health and reintegrate into his family and community.

Differential Diagnoses:

1. Bipolar Disorder: This is a mental condition that leads to unusual shifts in an individual’s mood, energy, activity levels, and concentration. According to Lane and  Smith (2023), bipolar disorder is characterized by recurrent episodes of mania and major depression. The patient, in this case, has a family history of bipolar disorder. His other symptoms include a decreased need for sleep, hyperactivity through excessive video game purchasing, hypersexuality, grandiose thinking, impulsivity through public exposure, and overspending money.
2. Schizoaffective disorder: According to Miller and Black (2019), schizoaffective disorder is a chronic mental health condition characterized by the presence of symptoms of a major mood episode, such as delusions, hallucinations, or disorganized speech. While the patient had mood episodes, schizoaffective disorder was ruled out due to the lack of chronic hallucinations or delusions.
3. Attention-Deficit/Hyperactivity Disorder (ADHD): According to Salari et al. (2023), ADHD is a set of behaviors that disrupt social status, including increased motor activity in inappropriate contexts, excessive wobbling, finger play, and talkativeness. In this case, the patient’s behavior is consistent with mood dysregulation, has an episodic nature of symptoms, and does not meet the ADHD diagnostic criteria.

 

Reflections:

The case presented a complex and challenging perspective on adolescent mood disorders, challenged my initial clinical reasoning, and emphasized the critical importance of comprehensive assessment. My preceptor’s diagnostic impression of Bipolar I Disorder is thoroughly substantiated through pertinent positive evidence. Among the things I would do differently in this case are comprehensive collateral assessment, detailed medication management, and holistic treatment planning. An ethical obligation to consider in the case is to ensure patient and community safety protection and effective risk management of potential inappropriate behaviors. The social determinants of health include socioeconomic factors such as barriers to consistent healthcare access and medication affordability. The cultural considerations to make in this case include the possible stigma of mental health conditions. Health promotion and disease prevention include early mood disorder intervention, family psychiatric history screening, and comprehensive education support.

 

References

Lane, N. M., & Smith, D. J. (2023). Bipolar disorder: Diagnosis, treatment and future directions. Journal of the Royal College of Physicians of Edinburgh, 53(3), 192-196. https://doi.org/10.1177/14782715231197577

Miller, J. N., & Black, D. W. (2019). Schizoaffective disorder: A review. Annals of clinical psychiatry: official journal of the American Academy of Clinical Psychiatrists, 31(1), 47-53.

Salari, N., Ghasemi, H., Abdoli, N., Rahmani, A., Shiri, M. H., Hashemian, A. H., … & Mohammadi, M. (2023). The global prevalence of ADHD in children and adolescents: a systematic review and meta-analysis. Italian journal of pediatrics, 49(1), 48. https://doi.org/10.1186/s13052-023-01456-1

NRNP_6635_Week3_Assignment_Rubric

Criteria	Ratings	Pts
This criterion is linked to a Learning OutcomeCreate documentation in the Comprehensive Psychiatric Evaluation Template about the patient you selected. 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• Allergies• ROS Assessing and Diagnosing Patients With Mood Disorders – Comprehensive Psychiatric Evaluation Template	20 to >17.0 ptsExcellentThe response throughly and accurately describes the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis. 17 to >15.0 ptsGoodThe response accurately describes the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis. 15 to >13.0 ptsFairThe response describes the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis, but is somewhat vague or contains minor innacuracies. 13 to >0 ptsPoorThe response provides an incomplete or inaccurate description of the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis. Or, subjective documentation is missing.	20 pts
This criterion is linked to a Learning OutcomeIn 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.	20 to >17.0 ptsExcellentThe response thoroughly and accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are thoroughly and accurately documented. 17 to >15.0 ptsGoodThe response accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are accurately documented. 15 to >13.0 ptsFairDocumentation of the patient’s physical exam is somewhat vague or contains minor innacuracies. Diagnostic tests and their results are documented but contain minor innacuracies. 13 to >0 ptsPoorThe response provides incomplete or inaccurate documentation of the patient’s physical exam. Systems may have been unnecessarily reviewed, or, objective documentation is missing.	20 pts
This criterion is linked to a Learning OutcomeIn 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-TR diagnostic criteria for each differential diagnosis and explain what DSM-5-TR 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.	25 to >22.0 ptsExcellentThe response thoroughly and accurately documents the results of the mental status exam. …Response lists at least three distinctly different and detailed possible disorders in order of priority for a differential diagnosis of the patient in the assigned case study, and it provides a thorough, accurate, and detailed justification for each of the disorders selected. 22 to >19.0 ptsGoodThe response accurately documents the results of the mental status exam. … Response lists at least three distinctly different and detailed possible disorders in order of priority for a differential diagnosis of the patient in the assigned case study, and it provides an accurate justification for each of the disorders selected. 19 to >17.0 ptsFairThe response documents the results of the mental status exam with some vagueness or inaccuracy. … Response lists at least three different possible disorders for a differential diagnosis of the patient and provides a justification for each, but may contain some vagueness or inaccuracy. 17 to >0 ptsPoorThe response provides an incomplete or inaccurate description of the results of the mental status exam and explanation of the differential diagnoses. Or, assessment documentation is missing.	25 pts
This criterion is linked to a Learning OutcomeReflect on this case. 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!), social determinates of health, 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.).	10 to >8.0 ptsExcellentReflections are thorough, thoughtful, and demonstrate critical thinking. 8 to >7.0 ptsGoodReflections demonstrate critical thinking. 7 to >6.0 ptsFairReflections are somewhat general or do not demonstrate critical thinking. 6 to >0 ptsPoorReflections are incomplete, inaccurate, or missing.	10 pts
This criterion is linked to a Learning OutcomeProvide at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support your diagnostics and differential diagnoses. Be sure they are current (no more than 5 years old).	15 to >13.0 ptsExcellentThe response provides at least three current, evidence-based resources from the literature to support the assessment and diagnosis of the patient in the assigned case study. The resources reflect the latest clinical guidelines and provide strong justification for decision making. 13 to >11.0 ptsGoodThe response provides at least three current, evidence-based resources from the literature that appropriately support the assessment and diagnosis of the patient in the assigned case study. 11 to >10.0 ptsFairThree evidence-based resources are provided to support assessment and diagnosis of the patient in the assigned case study, but they may only provide vague or weak justification. 10 to >0 ptsPoorTwo or fewer resources are provided to support assessment and diagnosis decisions. The resources may not be current or evidence based.	15 pts
This criterion is linked to a Learning OutcomeWritten Expression and Formatting—Paragraph development and organization:Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused—neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria.	5 to >4.0 ptsExcellentA clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria. …Paragraphs and sentences follow writing standards for flow, continuity, and clarity. 4 to >3.5 ptsGoodPurpose, introduction, and conclusion of the assignment are stated, yet they are brief and not descriptive. …Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. 3.5 to >3.0 ptsFairPurpose, introduction, and conclusion of the assignment is vague or off topic. … Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%-79% of the time. 3 to >0 ptsPoorNo purpose statement, introduction, or conclusion were provided. … Paragraphs and sentences follow writing standards for flow, continuity, and clarity less than 60% of the time.	5 pts
This criterion is linked to a Learning OutcomeWritten Expression and Formatting—English writing standards: Correct grammar, mechanics, and punctuation Assessing and Diagnosing Patients With Mood Disorders – Comprehensive Psychiatric Evaluation Template	5 to >4.0 ptsExcellentUses correct grammar, spelling, and punctuation with no errors 4 to >3.0 ptsGoodContains a few (one or two) grammar, spelling, and punctuation errors 3 to >2.0 ptsFairContains several (three or four) grammar, spelling, and punctuation errors 2 to >0 ptsPoorContains many (≥ five) grammar, spelling, and punctuation errors that interfere with the reader’s understanding	5 pts