Comprehensive Psychiatric Evaluation Note

  Below is a template for a Comprehensive Psychiatric Evaluation Note, tailored for a hypothetical patient who has undergone psychotherapy for a mood disorder over the last four weeks. Please adapt the details according to the specific case you have in mind. Comprehensive Psychiatric Evaluation Note Patient Name: Jane Doe Date of Evaluation: [Insert Date] Date of Birth: [Insert DOB] Gender: Female Referring Physician: [Insert Name] Evaluator: [Your Name & Credentials] Setting: Outpatient Therapy I. Identifying Information - Age: 28 - Marital Status: Single - Occupation: Marketing Specialist - Living Situation: Lives alone in an apartment II. Chief Complaint "Over the last month, I've been feeling really down and unmotivated. I just can't seem to shake it off." III. History of Present Illness Jane is a 28-year-old female who presents with symptoms consistent with Major Depressive Disorder (MDD). She reports experiencing persistent low mood, loss of interest in activities she once enjoyed, fatigue, and difficulty concentrating for the past four weeks. She also reports sleep disturbances, including insomnia and early morning awakening. Jane denies any suicidal ideation but expresses feelings of hopelessness. The onset of symptoms coincided with increased work stress and recent interpersonal conflicts with friends. Jane has been attending weekly psychotherapy sessions focused on cognitive-behavioral techniques to address her depressive symptoms. IV. Past Psychiatric History - Previous Diagnoses: Major Depressive Disorder (2019) - Prior Treatments: - Psychotherapy (CBT) – 6 months, completed in 2020 - Sertraline (Zoloft) – Discontinued due to side effects (nausea, weight gain) - Hospitalizations: None V. Medical History - Chronic Illnesses: None reported - Medications: None currently - Allergies: No known drug allergies VI. Family History - Father: History of depression - Mother: No psychiatric history; diabetes type II - Siblings: One sister with anxiety disorder VII. Social History Jane is currently single and lives alone. She works full-time as a marketing specialist and has a close-knit group of friends, although she reports feeling isolated lately. She denies substance use and engages in regular physical activity (yoga and running). VIII. Mental Status Examination - Appearance: Well-groomed, appropriate attire - Behavior: Cooperative but appears withdrawn - Mood/Affect: Mood is low; affect is restricted - Thought Process: Linear and goal-directed - Thought Content: No delusions or hallucinations; no suicidal or homicidal ideation - Cognition: Alert; orientation intact to time, place, and person - Insight/Judgment: Fair; recognizes need for help but struggles with self-motivation IX. Assessment Jane presents with symptoms consistent with Major Depressive Disorder. While she has previously responded to therapy, she currently faces challenges related to situational stressors. The psychotherapeutic approach focusing on cognitive-behavioral strategies will continue to be beneficial. X. Treatment Plan 1. Continue weekly psychotherapy sessions focused on cognitive-behavioral therapy. 2. Introduce mindfulness-based strategies to manage stress and anxiety. 3. Monitor mood symptoms closely; consider referral for psychiatric evaluation if no improvement is noted in six weeks. 4. Encourage Jane to engage in social activities to combat feelings of isolation. 5. Suggest maintaining a mood diary to track symptoms and triggers. Follow-Up Appointment: [Insert Date] Evaluator Signature: [Your Name, Credentials] [Your Contact Information] Please ensure that you adjust the details to reflect the specific patient’s information and circumstances accurately.

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