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Please see attached assignment and instructions. I have completed the first part of the assignment. The plan portion needs to be completed with references.Thank you
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Encounter date: 9/28/2023
Patient Initials: A.H Gender: Male Age: 16 Race: Black/African American Ethnicity: Black
Reason for Seeking Health Care: “There is person following me trying to hurt me”
HPI: A.H is a 16-year Black biological male that was admitted to Citrus Crisis Unit via
Professional Certificate from home after stating “There is a person following me trying to hurt
me” Patient’s mother stated he has not been taking his medication for over 6 weeks now. He has
been very erratic and easily agitated, “picking fights with his siblings”. Upon interview patient
states it started about one week ago when she stopped taking his medication. A.H has been
seeing this “black male figure for about a week now”. Patient reports “I am homeless there is a
person who is watching me”. He reports that this person told him that he was going “to kill him
and his family”. He reports that it was a black male who was coming around him and his friend
following him and his friends. He reports that this person has a tracker to find out where he is to
hurt him. It last about 45 minutes couple of times a day mostly at night. He states “I just tried to
defend myself. I think the medication is not working”. To alleviate his symptoms, he admits to
smoking marijuana and playing video games like Fort Nite and Call of duty and just “go to my
room and nobody bother me”. Mother expressed concerned about his son’s safety and brought
him to Crisis Unit.
SI/HI: Patient denies any Suicide or Homicide Ideation at this time
Sleep: Pt reports sleeping “okay” about 5hrs a night
Appetite: Pt reports good appetite ate his
breakfast this morning
Allergies(Drug/Food/Latex/Environmental/Herbal): Pt. denies any allergies to drug, food, latex.
Environmental or herbal allergies.
Current perception of Health:
Psychiatric History:
Excellent
Good
Fair Poor
Inpatient hospitalizations:
Diagnoses
Date
Hospital
June 2023
Kendall Regional
Schizophrenia
5 days
Outpatient psychiatric treatment:
Diagnoses
Length of Stay
Date
Hospital
June 2023
Baptist Health
Date
Length of Stay
Hospital
Schizophrenia
Follow-up/ psychiatric management
Detox/Inpatient substance treatment:
Diagnoses
Length of Stay
Not Applicable
History of suicide attempts and/or self injurious behaviors: No history of self-injurious behavior in the
past
Past Medical History
• Major/Chronic Illnesses: None reported
• Trauma/Injury: None reported
• Hospitalizations: None reported
Past Surgical History: None reported
Current psychotropic medications:
Zyprexa 2.5 mg PO QHS
Current prescription medications:
None reported
OTC/Nutritionals/Herbal/Complementary therapy: None reported
Substance use: (alcohol, marijuana, cocaine, caffeine, cigarettes)
Substance
Amount
Frequency
Length of Use
Marijuana
“1 joint”
everyday
Reports for about 6 months
Family Psychiatric History:
Mother: Alive; no health concerns
Father: alive; dx of HTN and High cholesterol
Maternal Grandmother: alive; dx of HTN, DM and arthritis
Maternal grandfather: Deceased at age 89 of stroke
Paternal Grandmother: Alive; unknown health diagnosis
Paternal grandfather: Alive; hx of Bipolar and major depression.
Social History
Lives: Single family House Marital Status: Single
Education: Student, highest level of education 8th grade
Employment Status: stuent Current/Previous occupation type: Not applicable
Exposure to: ___Smoke____ ETOH ____Recreational Drug Use: Marijuana 1 joint per
day
Sexual Orientation: Heterosexual Sexual Activity: Denies Contraception Use: Reports
no use
Family Composition: Lives with mother and maternal grandmother and 2 siblings one
10year old sister and a 5year old boy. His father lives there for about 4 days a week. He is
there “sometimes not all the time”
Other: (Place of birth, childhood hx, legal, living situations, hobbies, abuse hx,
trauma, violence, social network, marital hx: A.H was born and raised in Miami FL.
Lives with mother, maternal grandmother and two siblings. His father is couple of days a
week with them but doesn’t really “care about me”. He enjoys playing video games like
Fort Nite and Call of Duty and be in my room by myself.
Health Maintenance
Screening Tests: Mammogram, PSA, Colonoscopy, Pap Smear, Etc: Not applicable
Exposures: Not applicable
Immunization HX: Update as per mother’s report
Review of Systems:
General: Denies any fatigue, unintended weight loss or gain.
HEENT: Denies trauma or headaches Eyes denies eye pain and visual loss. Ears: ear discharge
and ear pain. Nose: denies having a stuffy nose and nasal congestion. Throat: denies soreness
and hoarseness.
Neck: Denies any nodules or difficulty swallowing. Denies any pain and stiffness.
Lungs: Denies any shortness of breath, coughing, sneezing, and wheezing.
Cardiovascular: Denies any palpitations or chest pains
Breast: Denies any lumps or discharge
GI: Denies any nausea, vomiting or diarrhea.
Male/female genital: Deferred
GU: Denies any hematuria, dysuria, or urinary retention
Neuro: AAOX3. Denies any dizziness.
Musculoskeletal: Denies muscle, joint, or back pain and stiffness
Activity & Exercise: Reports mostly staying in his room playing video games.
Psychosocial: Admits to mostly isolating himself
Derm: denies any lesions or rashes.
Nutrition: Reports good appetite
Sleep/Rest: Reports sleep “okay” 5 hours a niht
LMP: not applicable
STI Hx: Denies any history
Physical Exam
BP 121/83 T; 98.7 HR: 96 RR: 16 Ht. 5’10 Wt. 136lbs BMI (percentile) 19.5
General: Appears well nourished, well developed male
HEENT: deferred
Neck: deferred
Pulmonary: deferred
Cardiovascular: deferred
Breast: deferred
GI: deferred
Male/female genital: deferred
GU: deferred
Neuro: AAOX3
Musculoskeletal: Normal range
Derm: deferred
Psychosocial: denies any suicide or homicide ideations
Misc.
Mental Status Exam
Appearance: Casual, good hygiene, appears stated age
Behavior: Calm and cooperative observed being argumentative, defiant, and overall oppositional;
minimizes
Speech: Clear and comprehensible, with normal tone and rate
Mood: “I’m okay”
Affect: Constricted
Thought Content: No delusions and/or mental preoccupations elicited/noted. Presents somewhat
paranoid and pessimistic.
Thought Process: no evidence of disorganization.
Cognition/Intelligence: Fair
Clinical Insight: limited to poor.
Clinical Judgment: limited to poor.
Significant Data/Contributing
Dx/Labs/Misc.
Denies
any suicide or homicidal ideation
Denies any visual or auditory hallucinations at time of interview
Plan:
Differential Diagnoses
1.
2.
Principal Diagnoses
1. Schizophrenia
2. Cannabis use disorder
Plan
Diagnosis #1
Diagnostic Testing/Screening:
Pharmacological Treatment:
Non-Pharmacological Treatment:
Education:
Referrals:
Follow-up:
Anticipatory Guidance:
Diagnosis #2
Diagnostic Testingg/Screenin:
Pharmacological Treatment:
Non-Pharmacological Treatment:
Education:
Referrals:
Follow-up:
Anticipatory Guidance:
Step 1: You will use the Graduate Comprehensive Psychiatric Evaluation Template Download Graduate Comprehensive
Psychiatric Evaluation Templateto:
1. Compose a written comprehensive psychiatric evaluation of a patient you have seen in the clinic.
2. Upload your completed comprehensive psychiatric evaluation as a Word doc. Scanned PDFs will not be
accepted
3. Please remember your History of Present Illness (HPI) should tell a story about your patient Includes the
presenting problem and the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character,
Aggravating factors, Relieving factors, Timing and Severity). The HPI and history should support the patient’s
DSM5-TR diagnosis at all times.
SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan.
S=
Subjective data: Patient’s Chief Complaint (CC); History of the Present Illness (HPI)/ Demographics; History of the Present Illness (HPI) that
includes the presenting problem and the 8 dimensions of the problem (OLDCARTS or PQRST); Review of Systems (ROS)
O=
Objective data: Medications; Allergies; Past medical history; Family psychiatric 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 ICD-10 and DSM5 codes
P=
Plan: Pharmacologic and Non-pharmacologic treatment plan; diagnostic testing/screening tools, patient/family teaching, referral, and follow
up
Other: Incorporate current clinical guidelines NIH Clinical GuidelinesLinks to an external site. or APA Clinical
GuidelinesLinks to an external site., research articles, and the role of the PMHNP in your evaluation.
•
•
Psychiatric Assessment of Infants and ToddlersLinks to an external site.
Psychiatric Assessment of Children and AdolescentsLinks to an external site.
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