Comprehensive Psychiatric Evaluation

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Writer and Vincent met for bio assessment. Pt calm and cooperative. Oriented to person, place, time. Open and engaged. Pt was comfortable answering all questions.

Pt is 57 year old white male admitted for ETOH abuse. Pt’s first time in treatment with no significant time abstinent. Medical Hx: HIV positive, HTN. Pt compliant with medications. Patient prescribed Norvasc and Odefsey. Pt denies psychiatric hx, although patient had been feeling depressed for the first few months of Covid. No history of suicidal or homicidal thoughts. Pt has no current legal problems. Pt currently employed as a bartender. Pt financially stable due to work and receiving part-time unemployment. Pt in a same-sex relationship with partner for the last 30 years. Stable living environment. Pt plans to return to his home after discharge

Assessment:

D1 – Pt denies any physical symptoms of ETOH withdrawal

D2 – Medical diagnoses include being positive for HIV and hypertension. Pt compliant with medication regimen. No complaints of side effects

D3 – No official psychiatric diagnoses. Pt reported feelings of depression during first few months of Covid (pt was not able to work and didn’t have

D4 – Pt is contemplative state. Pt shows willingness to participate in recovery

D5- Risk factor is pt’s occupation. Pt works as a bartender

D6 – Pt reports being financially stable at the moment. Pt plans on returning home after treatment, where has lived with his spouse for the past 30 years. Pt has no plan for aftercare but is willing to take direction

Plan:

Pt will follow up with assigned tx team to begin identifying goals for treatment

Also see: Psychiatric-mental health

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

Last Updated on January 7, 2021 by Essay Pro