ASSESSING AND DIAGNOSING PATIENTS WITH MOOD DISORDERS

TO PREPARE:

  • Review this week’s Learning Resources. Consider the insights they provide about assessing and diagnosing mood disorders.
  • Download the Comprehensive Psychiatric Evaluation Template, which you will use to complete this Assignment. Also review the Comprehensive Psychiatric Evaluation Exemplar to see an example of a completed evaluation document.
  • By Day 1 of this week, select a specific video case study to use for this Assignment from the Video Case Selections choices in the Learning Resources. View your assigned video case and review the additional data for the case in the “Case History Reports” document, keeping the requirements of the evaluation template in mind.
  • Consider what history would be necessary to collect from this patient.
  • Consider what interview questions you would need to ask this patient.
  • Identify at least three possible differential diagnoses for the patient.

BY DAY 7 OF WEEK 3

Complete and submit your Comprehensive Psychiatric Evaluation, including your differential diagnosis and critical-thinking process to formulate a primary diagnosis. Incorporate the following into your responses in the template:

  • Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life?
  • Objective: What observations did you make during the psychiatric assessment?
  • Assessment: Discuss the patient’s mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses with supporting evidence, listed in order from highest priority to lowest priority. Compare the DSM-5-TR 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.
  • Reflection notes: What would you do differently with this client if you could conduct the session over? 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.).

 

LEARNING RESOURCES

Required Readings

American Psychiatric Association. (2022). Bipolar and related disorders. In Diagnostic and statistical manual of mental disorders Links to an external site.(5th ed., text rev.). https://go.openathens.net/redirector/waldenu.edu?url= https://dsm.psychiatryonline.org/doi/full/10.1176/appi.books.9780890425787.x03_Bipolar_and_Related_Disorders

American Psychiatric Association. (2022). Depressive disorders. In Diagnostic and statistical manual of mental disorders Links to an external site.(5th ed., text rev.). https://go.openathens.net/redirector/waldenu.edu?url=https://dsm.psychiatryonline.org/doi/full/10.1176/appi.books.9780890425787.x04_Depressive_Disorders

Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan & Sadock’s synopsis of psychiatry (11th ed.). Wolters Kluwer.

Chapter 8, Mood Disorders

Chapter 31, Child Psychiatry (Section 31.12 only)

 

 

 

  • my video selection-
  •  Symptom Media. (Producer). (2018). Training title 118 Links to an external site.[Video]. https://go.openathens.net/redirector/waldenu.edu?url=https://video.alexanderstreet.com/watch/training-title-118
  •  

Training Title 118 

Name: Mr. Connor Walsh 
Gender: male 
Age: 57 years old 
T- 97.2 P- 94 R 20 156/88 Ht 5’8 Wt 163lbs 
Background: Born and raised in Peru Indiana Is staying at a shelter after being homeless in 
MacArthur Park for 1 year in Los Angeles. He lost his apartment and his job working part-time 
at Home Depot. Enjoys playing music. He has long hx of mental health treatment since age 19. 
Previous medication trials include lithium (was effective), Depakote (gastric upset), aripiprazole 
(akathisia), risperidone (hyperprolactinemia), haloperidol (dystonia), quetiapine (didn’t give a 
fair trial), Poor historian. divorced once, reports being gay, no children; estranged from only 
living sister, parents deceased. He is not sure of his family mental health or substance use history 
but feels like he is most like his aunt, she has history of mental health treatment “but 
I’m not sure for what.” States that he got a master’s degree in music theory at Stanford. Admits 
to 3-6 drinks of alcohol when “playing music in the clubs”, denied illicit drugs, has history of 
intentional drug overdose at age 22, history of 8 inpatient psychiatric hospitalization, most recent 
was 8 months ago. hx of one detox admission 15 years ago Allergies: bee stings 

Symptom Media. (Producer). (2018). Training title 118 [Video]. https://video-alexanderstreet-
com.ezp.waldenulibrary.org/watch/training-title-118 

 

*please use the following Template – week 3 

Week (enter week #): (Enter assignment title)
Student Name
College of Nursing-PMHNP, Walden University
NRNP 6635: Psychopathology and Diagnostic Reasoning
Faculty Name
Assignment Due Date

 

 

NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template
© 2021 Walden University Page 2 of 3
Subjective:
CC (chief complaint): 
HPI: 
Past Psychiatric History: 
ï‚· General Statement: 
ï‚· Caregivers (if applicable):
ï‚· Hospitalizations: 
ï‚· Medication trials: 
ï‚· Psychotherapy or Previous Psychiatric Diagnosis: 
Substance Current Use and History: 
Family Psychiatric/Substance Use History: 
Psychosocial History: 
Medical History: 
ï‚· Current Medications: 
ï‚· Allergies: 
ï‚· Reproductive Hx: 
ROS: 
ï‚· GENERAL: 
ï‚· HEENT: 
ï‚· SKIN: 
ï‚· CARDIOVASCULAR: 
ï‚· RESPIRATORY: 
ï‚· GASTROINTESTINAL: 
ï‚· GENITOURINARY: 
ï‚· NEUROLOGICAL: 
ï‚· MUSCULOSKELETAL: 
ï‚· HEMATOLOGIC: 
ï‚· LYMPHATICS: 
ï‚· ENDOCRINOLOGIC: 
Objective:
Physical exam: if applicable

 

 

NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template
© 2021 Walden University Page 3 of 3
Diagnostic results: 
Assessment:
Mental Status Examination: 
Differential Diagnoses: 
Reflections:

 

 

 

 

**The following is the Exemplar

NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Exemplar
© 2021 Walden University Page 1 of 6
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 AND 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
• Allergies
• ROS
• 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-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.
• 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

 

 

NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Exemplar
© 2021 Walden University Page 2 of 6
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.). 
(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.
Or
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-TR 
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.

 

 

NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Exemplar
© 2021 Walden University Page 3 of 6
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?
Educational Level
Hobbies:
Work History: currently working/profession, disabled, unemployed, retired?
Legal history: past hx, any current issues?

 

 

NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Exemplar
© 2021 Walden University Page 4 of 6
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.

 

 

NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Exemplar
© 2021 Walden University Page 5 of 6
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).
Assessment
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 
diagnostic impression selection. You will use supporting evidence from the literature to

 

 

NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Exemplar
© 2021 Walden University Page 6 of 6
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!), 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.).
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

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