Comprehensive Psychiatric Evaluation Essay

The Assignment

Document the following for the family in the video, using the Comprehensive Evaluation Note Template:

Chief complaint
History of present illness
Past psychiatric history
Substance use history
Family psychiatric/substance use history
Psychosocial history/Developmental history
Medical history
Review of systems (ROS)
Physical assessment (if applicable)
Mental status exam
Differential diagnosis—Include a minimum of three differential diagnoses and include how you derived each diagnosis in accordance with DSM-5 diagnostic criteria
Case formulation and treatment plan
Include a psychotherapy genogram for the family
Note: For any item you are unable to address from the video, explain how you would gather this information and why it is important for diagnosis and treatment planning.  Comprehensive Psychiatric Evaluation Essay


1} Document the following for the family in the video, using the Comprehensive Evaluation Note Template: • Chief complaint • History of present illness • Past psychiatric history • Substance use history • Family psychiatric/substance use history • Psychosocial history/Developmental history • Medical history • Review of systems (ROS) • Physical assessment (if applicable)

2} Mental status exam • Differential diagnoses—Include a minimum of three differential diagnoses and include how you derived at each diagnosis in accordance with DSM-5 diagnostic criteria

3} • Case formulation • Treatment plan that includes psychotherapy interventions

4} A psychotherapy genogram for the family

Learning Resources

Required/ Optional Readings (click to expand/reduce)

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.)

For reference as needed
Nichols, M., & Davis, S. D. (2020). The essentials of family therapy (7th ed.). Pearson.


Chapter 2, “Basic Techniques of Family Therapy”
Chapter 3, “The Fundamental Concepts of Family Therapy”
Chapter 4, “Bowen Family Systems Therapy
Therapist Aid. (2012–2020). Genograms for psychotherapy.

Therapist Aid LLC. (© 2012-2020). Genograms for psychotherapy.

Document: Comprehensive Psychiatric Evaluation Note Template

Document: Comprehensive Psychiatric Evaluation Note Exemplar

Required Media (click to expand/reduce)

Gehart, D. R. (2013, August 29). Progress note [Video]. YouTube.

Masterswork Productions. (2003). Mother and daughter: A cultural tale [Video/DVD].

Sommers-Flanagan, J., & Sommers-Flanagan, R. (2013). Counseling and psychotherapy theories in context and practice [Video]., Comprehensive Psychiatric Evaluation Essay


Mother of Five and 23 Year-Old Daughter of Iranian Descent: Comprehensive Psychiatric Evaluation

Patti is an Iranian immigrant to the United States. She has come to the clinic with her 23 year-old daughter (Sharleen) for consultation. Present in the interview conducted by Dr. Gonzalo Bacigalupe is their therapist Sandi. The family has needed therapy because of the psychological trauma caused by issues such as domestic violence, child molestation, and family separation. Patti is disabled after a failed bilateral surgery on her lower limbs. She is unable to provide for herself but unfortunately all the five children including Sharleen have little time for her. They have discarded their Iranian cultural roots and underwent acculturation to the American way of life. This paper is a comprehensive psychiatric evaluation of Patti and her family, represented by herself and her daughter in this interview.


CC (chief complaint): Patti feels sad because of her husband’s sexual assault on her daughter Shireen. She also feels lonely because the children have abandoned her despite her disability.

HPI: The patient is an Iranian female immigrant who is also a mother of five. There is no previous history of her present condition. The onset of symptoms was when Shireen came to the US and told her that her father raped her. That was also the time that she became disabled after the failed surgeries. The symptoms are mainly psychological but she also has physical pain from the failed operation sites. The symptoms of sadness and loneliness are constant in nature. They are severe and get aggravated by the children’s absence. The symptoms get relieved when her children come visiting. She rates her symptom severity at 7/10.

Past Psychiatric History:

  • General Statement: he patient came to the US as an adult and is still influenced by her Iranian culture and religion. Her children have been accultured to the US liberal culture. This has brought conflicts between her and the family.
  • Caregivers (if applicable): Since she is disabled now and cannot walk, she needs caregivers.
  • Hospitalizations: She was hospitalized for the two lower limb surgeries that failed.
  • Medication trials: She has never been a part of any medication trials.
  • Psychotherapy or Previous Psychiatric Diagnosis: She does not have any previous history of psychiatric illness or psychotherapy.

Substance Current Use and History: There is no history of substance use in the family.

Family Psychiatric/Substance Use History: The only significant psychiatric history is the pedophilic disorder exhibited by the husband when he raped her then 10 year-old daughter back in Iran.  Comprehensive Psychiatric Evaluation Essay

Psychosocial History: The patient is influenced by her Iranian community culture of a closely knit family. She was staying with her children until they came of age and decided to leave home and seek their freedom. She has a relative in the US living in another state and as result they do not see each other as often.

Medical History: There is no significant medical history apart from the recent surgical history (failed lower limb surgeries).

  • Current Medications: Ibuprofen 500 mg TDS
  • Allergies: NKDA
  • Reproductive Hx: A mother of five – three girls and two boys.


General: She denies fatigue, weight loss, and fever.

Musculoskeletal: She reports muscle and joint pain in the lower limbs as well as los of function and stiffness of joints.

Others: She denies any problems with all the other systems.


Diagnostic results: Lower limb X-rays show no fractures. The full blood count also shows a normal count and differentials.


Mental Status Examination: The patient is a middle-aged Iranian immigrant female. She is alert and oriented in all respects. Her dressing is appropriate and her speech is clear. She has no visible mannerisms or tics. Being sad is her self-reported mood. Her affect is dysphoric. She does not hallucinate and is not deluded. She also has no homicidal or suicidal ideation. Her judgment and insight are not affected and the diagnosis is major depressive disorder or MDD (Sadock et al., 2015APA, 2013).

Differential Diagnoses:

  1. MDD: She is lonely and sad and meets the DSM-5 diagnostic criteria for MDD. For instance, she displays depressed mood most of the time and does not enjoy pleasurable activities (Sadock et al., 2015APA, 2013).
  2. Post-traumatic Stress Disorder (PTSD): She went through the trauma of domestic violence and the rape f her daughter by her own father.
  3. Separation Anxiety Disorder: She has been left alone by her children who are now leading their own lives.

Reflections: This psychiatric evaluation was carried out comprehensively and I would do it the very same way given another chance. Autonomy was observed with respect to informed consent. Health education was on family therapy to help the family cope.

Case Formulation and Treatment Plan: This will involve both medications and therapy. For medications, a selective serotonin reuptake inhibitor will be suitable. In this case, sertraline (Zoloft) 100 mg orally daily will do (Katzung, 2018; Stahl, 2017). Therapy will involve group cognitive behavioral therapy (CBT) and family therapy (Wheeler, 2020; Corey, 2017, Yalom & Leszcz, 2005).


Family Genogram


American Psychiatric Association [APA] (2013). Diagnostic and Statistical Manual of Mental Disorders (DSM-5), 5th ed. Author.

Ball, J., Dains, J.E., Flynn, J.A., Solomon, B.S., & Stewart, R.W. (2019). Seidel’s guide to physical examination: An interprofessional approach, 9th ed. Elsevier.

Bickley, L.S. (2017). Bates’ guide to physical examination and history taking, 12th ed. Wolters Kluwer.

Corey, G. (2017). Theory and practice of counselling and psychotherapy, 10th ed. Cengage Learning.

Katzung, B.G. (Ed) (2018). Basic and clinical pharmacology, 14th ed. McGraw-Hill Education.

Mother and Daughter : A Cultural Tale (2003). [Video/ DVD] Masterswork Productions.

Sadock, B.J., Sadock, V.A., & Ruiz, P. (2015). Synopsis of psychiatry: Behavioral sciences clinical psychiatry, 11th ed. Wolters Kluwer.

Stahl, S.M. (2017). Stahl’s essential psychopharmacology: Prescriber’s guide, 6th ed. Cambridge University Press.

Wheeler, K. (2020). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice, 3rd ed. Springer Publishing Company, LLC.

Yalom, I.D., & Leszcz, M. (2005). The theory and practice of group psychotherapy, 5th ed. Basic Books.

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:


Diagnostic results:


Mental Status Examination:

Differential Diagnoses:


Case Formulation and Treatment Plan:

Comprehensive Psychiatric Evaluation Essay








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