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Psychiatric Evaluation

Could you read the following Psych Evaluation and write a response, just one page, with 2 APA scholarly references, no first page is needed. The rationale for agreeing or disagreeing with the diagnosis and treatment/plan?



CC (chief complaint): I sometimes feels scared and sad, telling myself I am not good enough.

HPI: The patient N.B is a 16-year-old Hispanic female who presented to the clinic accompanied by her mother for an initial psychiatric evaluation. The patient complained of feeling scared and sad, sometimes telling herself she was not good enough. She reports feeling tired with no desire to do anything. She has lost pleasurable interest in activities, wants to be left alone, cries frequently, worries a lot, and feels jittery and anxious. She also reported she got afraid that something terrible may happen to her, felt on edge, and had sudden obsessive thoughts. N.B feels worthless, helpless, hopeless, has racing thoughts, highly stressed, irritable, loss of appetite, not able to sleep at night but feels sleepier during the day. She reported rape by a family friend when she was fourteen years old, she did not report it, and it has been hunting her these days. N.B is a mother of a four-month-old baby boy, and she reported experiencing these symptoms before having her baby but got worsened after the delivery of her son. She said that even though it worsens after the baby is born, she gets great joy anytime she sees her son. She reported having a prior thought of suicide sometimes and still feels the same due to low self-esteem. She has no self-mutilation, and her son is the one keeping her ongoing. She, however, denies homicidal ideations or thoughts. She endorses auditory and visual hallucinations and flashbacks from the rape incident but no delusional thoughts. She rated her mood as 7/10 and Anxiety as 8/10. Even though she does not enjoy school because she cannot focus on school activities and gets distracted easily, her goal is to go to college. She lives with her mother and two brothers, and maternal grandparents. Her coping skill is doing house chores; staying idle worsens her symptoms.

Substance Current Use: N.B denies alcohol use; she does not smoke marijuana and does not use any illicit drug.

Medical History: N.B denies any medical issues.

Current Medications:    N.B was prescribed Prozac 10mg tablet, one tablet once a day for 30 days with no refill.

Allergies: She denies any drug, food, or seasonal allergies.

Reproductive Hx: N.B is a single mother of a four-month-old baby boy, she is not breastfeeding, gravida 1, para 1, heterosexual and has regular monthly menstrual flow.


      GENERAL: N.B presented to the clinic well-groomed and appropriately dressed for the weather. She appeared her stated age, denies fever, and have weight loss due to loss of appetite. She denies night sweats, seemed worried, and had depressive symptoms. She is alert and oriented to person, place, time, and situation.

        HEENT: Head is normocephalic; she denies head trauma. Eyes: She does not wear glasses, denies double or blurred vision, and has no conjunctivitis. Ear: She denies hearing difficulties, tinnitus, and no earache or drainage voiced.  Nose: she denies sneezing, rhinorrhea, and rhinitis. Mouth: she denies dental caries, no gingivitis or periodontal disease, and oral mucosa is pink and moist. Throat: she denies having a sore throat, no swollen lymph nodes, or jugular distension.

      SKIN: The patient denies pruritis, bruising, or any open areas on the skin.

       CARDIOVASCULAR: N.B denies chest discomfort and tightness.

      RESPIRATORY: The patient denies respiratory distress, no SOB or cough.

      GASTROINTESTINAL: The patient denies constipation or diarrhea.

      GENITOURINARY: N.B denies frequency or urgency in urination, no dysuria.

      NEUROLOGICAL: N.B denies headache or syncope.

       MUSCULOSKELETAL: The patient denies myalgia, no joint pain.

      HEMATOLOGIC: The patient denies any abnormal bleeding or bruising.

      LYMPHATICS: The patient denies lymphadenopathy, no splenomegaly

       ENDOCRINOLOGIC: The patient denies cold or heats intolerance, no polydipsia, polyuria, or polyphagia.


Vital signs:  B/P 118/66, HR 92, RR 18, SaO2 100%, wt 132 lbs, ht 5’5′ BMI 22 kg/m2 ( Normal).

GENERAL: The patient present with her stated age, appropriately dressed in good hygiene and well groomed. She appeared sad, worried with depressive symptoms. She denies unexplained weight loss, no night sweats, fever, or chills. She expresses loss of appetite.

HEENT: Normocephalic head, no trauma. Eye: Equal, brisk, and reactive to light.  Ears: ears are symmetrical, no deformities. Nose: No rhinitis or sneezing. Mouth: pink and moist oral mucosa, no dental carries. Neck: is supple, no lymph nodes, swallowing difficulties or sore throat.

SKIN: Intact with no open areas.

CARDIOVASCULAR: No chest pain, peripheral edema noted.

RESPIRATORY: No cough, wheezing, or shortness of breath. Breathing even and unlabored.

GASTROINTESTINAL: No heartburn, N/V or constipation noted.

GENITOURINARY: No dysuria, urinary frequency or urinary incontinence noted.

NEUROLOGICAL: No headaches, syncope, or seizures noted.

MUSCULOSKELETAL: No joint pain, swelling, or myalgias noted.

HEMATOLOGIC: No bleeding, or bruising noted.

LYMPHATICS: No visible swollen lymph nodes or glands noted.

Diagnostic Test:

PHQ-9 score: 17, moderately severe depression.

Generalized Anxiety Disorder Assessment (GAD-7): 20/21: indications of severe anxiety.

Laboratory Investigations:

Complete Blood Count (CBC): Normal

Comprehensive Metabolic Panel (CMP): Normal

Thyroid Stimulating Hormone (TSH): normal.

Lipid Panel: normal.

Urinary drug screening (UDS): Negative

EKG: normal.

C-Reactive Protein: 12 mg/L (abnormal).


Mental Status Examination:

N.B is a 16-year-old Hispanic female patient who presented to the clinic with her mother for an initial psychiatric visit. The patient appeared medium build and looked her stated age with good personal hygiene and grooming, and casually dressed for the weather. The patient is alert and oriented to person, place, time, and situation. No Tic or gait abnormality; she tried to maintain eye contact during our conversation but got easily distracted. Her remote memory is intact; her speech is spontaneous with normal rate, volume, and articulation. The language was fluentno sign of tangential speech. She has depressive and anxious moods, affect is congruent, thought process is goal-directed, no flight of ideas or looseness of association. Her thought content is appropriate and focused on recovery. She endorsed auditory and visual hallucinations and flashbacks, mostly at night. She denies self-mutilations have suicidal thoughts sometimes but no homicidal thoughts or ideation and no delusional thoughts. Her insight, judgment, and thought are fairno gross mental defects.

Diagnostic Impression:

Major Depression Disorder (MDD)

MDD is diagnosed after the patient experience at least five symptoms which consist of changes in persistently low or depressed mood, appetite, and weight, changes in sleep and activities, anhedonia, fatigue, feeling of guilt, problem decision making, poor focus, decreased pleasure in desirable things and suicidal thoughts (Urrila et al., 2020). It is caused by multiple factors, which includes biological, genetic, and psychosocial factors and it is a deficiency caused by neurotransmitters such as serotonin, norepinephrine, and dopamine in the brain  (Urrila et al., 2020). The patient reports similar symptoms, and based on DSM-5 criteria for diagnosis, which point to the same symptoms mentioned above, N.B has a diagnosis of MDD.

Generalized Anxiety Disorder (GAD)

According to the DSM-5 diagnostic criteria for GAD, the individual must exhibit the symptoms of excessive worries and anxiety, tiredness than usual, increased muscle tension, restlessness at night, irritability, inability to concentrate, fear, loneliness, and lack of sleep (Creighton et al., 2019). N.B has been experiencing the same symptoms above, making GAD a possible diagnosis.

Post-Traumatic Stress Disorder (PTSD)

According to the DSM-5 diagnostic criteria for PTSD, the individual must have exposure to an actual event or threatened death, serious injury, or sexual violence. It can be in several ways, eighter direct encounter with the traumatic event, witnessing a traumatic event, threatening event to a friend or family member, or experiencing repeated exposure to a traumatic situation (Fung et al., 2019). N.B reported she was experiencing flashbacks from a rape event, a possible diagnosis of PTSD.


The patient N.B is a 16-year-old with a four-month-old son going through mental challenges with depressive symptoms, anxiety, and traumatic stress. She was started on her first pharmacological intervention with Prozac to manage her symptoms. She was informed about the importance of medication compliance as the efficacy of the medication regimen will depend on her adherence. Psychoeducation was given about the medication’s side effects and how to report unwanted side effects asap. Though her mother has been her support person, she might face some financial issues as she is unemployed and in school 9th now. Therefore, it is imperative to ascertain her socioeconomic background: thus, easy transportation access to the clinic or health centers, and how to fill her medications. If there are challenges in getting her prescribed medicine served, it could be a barrier to successful treatment outcomes. I implemented health promotion needs on a healthy diet, exercise, smoking, and illicit drug use avoidance. I maintained respect for patient rights, privacy, and confidentiality. I also implemented the standard of the bioethical principle of nonmaleficence and beneficence. The patient was shown empathy, non-judgmental, and biased treatment to enhance maximum benefit from the treatment and develop the therapeutic relationship.

Case Formulation and Treatment Plan:

Pharmacological Method:

           Prozac 10mg tablet, one tablet by mouth once a day x 30 days with no refill for Depression

           The Possible side effects and adverse effects of the medications were discussed with the patient.

Non-Pharmacological Method

Combining psychotherapy with Cognitive Behavioral Therapy (CBT) and Movement Desensitization and Processing (EMDR) was recommended for the patient to help her focus on her problems and find solutions to them. These treatments will also helps her to deal with current issues, to help herself after the therapy. She should be able to cope with life again after therapy and ignore past experiences by changing current distressing thoughts and behavioral patterns (Denecke et al., 2022). The rapid and rhythmic eye movement will aid to reduce and resolve past traumatic events.


            I discussed Psychoeducation and Brief supportive therapy about medication side effects, medications compliance, and the duration of expected outcomes for the medication with the patient. The current medication’s risks/benefits/alternatives were also discussed in detail, and the patient verbalized understanding and agreed with the plan. Health promotions on healthy sleep hygiene, daily exercises, healthy diet, avoidance of smoking or illicit drug use, lifestyle modification, and the importance of adopting a coping mechanism to manage symptoms. The patient was allowed to ask questions and expressed her concern and satisfaction with the treatment plan. She was able to voice understanding of the medication regimen, comprising how to take it, stowage, purpose, dangers, advantages, and side effects. The patient can express the method for acquiring or requesting a modification of drugs. Incorporating treatments into the patient lifestyle has been contemplated – comprising any challenges. I established a follow-up plan for her to return in two weeks, and the patient agreed to the plan.

Safety Plan

The patient knows that she may call the clinic about any medication alarms or interchange his subsequent appointment with an earlier one to address issues. The patient also comprehends that she can call the clinic during office periods if any difficulties surface. In case of an emergency, she understands to call 911 or go to the nearest emergency room or urgent care if her symptoms worsen or if she notices any other psychiatric symptoms that may pose a risk to her safety and others.


Creighton, A. S., Kissane, D. W., & Davison, T. E. (2019). The psychometric properties, sensitivity and specificity of the geriatric anxiety inventory, hospital anxiety and depression scale, and rating anxiety in dementia scale in aged care residents. Aging & Mental Health, 23(5), 633642. https://doi.org/10.1080/13607863.2018.1439882

Denecke, K., Schmid, N., & Nssli, S. (2022). Implementation of Cognitive Behavioral Therapy in e-Mental Health Apps: Literature Review. Journal of Medical Internet Research, 24(3), e27791. https://doi.org/10.2196/27791

Fung, H. W., Chan, C., Lee, C. Y., & Ross, C. A. (2019). Using the Post-traumatic Stress Disorder (PTSD) Checklist for DSM-5 to Screen for PTSD in the Chinese Context: A Pilot Study in a Psychiatric Sample. Journal of Evidence-Based Social Work (2019), 16(6), 643651. https://doi.org/10.1080/26408066.2019.1676858

Rothschild, A. J. (2016). Treatment for Major Depression With Psychotic Features (Psychotic Depression). Focus: Journal of Lifelong Learning in Psychiatry, 14(2), 207209. https://doi.org/10.1176/appi.focus.20150045

Urrila, A. S., Kiviruusu, O., Haravuori, H., Karlsson, L., Vierti, S., Suvisaari, J., & Marttunen, M. (2020). Sleep symptoms and long-term outcome in adolescents with major depressive disorder: A naturalistic follow-up study. European Child & Adolescent Psychiatry, 29(5), 595603. https://doi.org/10.1007/s00787-019-01436-z

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