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V. Past Medical History

• Medical Conditions: [List any known medical conditions]
• Surgeries: [List any previous surgeries]
• Allergies: [List any allergies]
• Medications: [List current medications]
• Immunizations: [List immunization history]

VI. Family History

• Mental Health: [Inquire about mental health history in first-degree relatives, such as depression, anxiety, bipolar disorder, schizophrenia]
• Substance Use: [Inquire about substance use history in first-degree relatives, such as alcoholism, drug addiction]
• Medical Conditions: [Inquire about any significant medical conditions in first-degree relatives, such as heart disease, diabetes, cancer]

VII. Social History

• Living Situation: [Describe current living situation]
• Social Support: [Assess social support network and quality of relationships]
• Occupation: [Describe current employment status, job satisfaction, and any occupational stressors]
• Education: [Describe educational background and any academic achievements]
• Legal History: [Inquire about any legal issues]
• Military History: [Inquire about any military service]
• Hobbies and Interests: [Inquire about hobbies, interests, and leisure activities]
• Substance Use: [Assess current and past substance use, including alcohol, tobacco, and illicit drugs]
• Sexual History: [Obtain relevant sexual history information as appropriate]

VIII. Mental Status Examination

• Appearance: [Describe patient's appearance, including dress, hygiene, and overall grooming]
• Behavior: [Observe patient's behavior, including eye contact, psychomotor activity, and any unusual movements]
• Speech: [Describe patient's speech pattern, including rate, volume, and clarity]
• Mood: [Inquire about patient's subjective mood and observe objective mood]
• Affect: [Observe range, appropriateness, and reactivity of affect]
• Thought Process: [Assess thought process, noting any evidence of flight of ideas, loose associations, or tangential thinking]
• Thought Content: [Assess thought content, specifically inquiring about suicidal ideation, homicidal ideation, delusions, and obsessions]
• Perception: [Assess for hallucinations (auditory, visual, tactile, olfactory, gustatory)]
• Cognition:
  • Orientation: Oriented to person, place, and time.
  • Attention and Concentration: [Assess attention and concentration, e.g., digit span, serial 7s]
  • Memory:
    • Immediate Recall: [Assess immediate recall, e.g., 3-item recall]
    • Short-Term Memory: [Assess short-term memory, e.g., recall of 3 items after a brief delay]
    • Long-Term Memory: [Assess long-term memory, e.g., recall of past personal and historical events]
  • Judgment and Insight: [Assess judgment and insight regarding current problems and their potential consequences]
• Abstraction: [Assess ability to understand abstract concepts, e.g., interpreting proverbs]
• Fund of Knowledge: [Assess general knowledge and awareness of current events]
• Insight and Judgment: [Assess patient's understanding of his current difficulties and his ability to make sound decisions]

IX. Diagnostic Impressions

• Primary Diagnosis:
  • Insomnia Disorder: The patient's primary complaint is persistent difficulty initiating and maintaining sleep, significantly impacting his daily functioning.
• Differential Diagnoses:
  • Major Depressive Disorder: While the patient reports mild depressive symptoms, the primary concern appears to be insomnia.
  • Generalized Anxiety Disorder: While anxiety is present, it appears to be secondary to sleep disturbance rather than the primary concern.
  • Alcohol Use Disorder: While the patient reports increased alcohol consumption, it is unclear if this constitutes a full-blown disorder at this time. Further assessment is needed to determine the severity and impact of alcohol use.

X. Treatment Plan

• Psychotherapy:
  • Cognitive-Behavioral Therapy for Insomnia (CBT-I): Recommended to address sleep hygiene, cognitive restructuring, and relaxation techniques.
• Pharmacotherapy:
  • Consider short-term use of over-the-counter sleep aids (e.g., melatonin) for symptom relief.
  • If insomnia persists or significantly impacts daily functioning, prescription sleep medications may be considered.
• Lifestyle Modifications:
  • Sleep Hygiene:
    • Maintain a regular sleep schedule.
    • Create a relaxing bedtime routine.
    • Optimize the sleep environment (dark, quiet, cool).
    • Avoid caffeine and alcohol before bed.
    • Limit screen time before bed.
    • Engage in regular physical activity during the day.
• Alcohol Use:
  • Brief Intervention: Provide brief counseling regarding the potential risks of alcohol use and encourage alcohol reduction.
  • Refer for further assessment: If alcohol use is determined to be problematic, refer the patient for further assessment and treatment by a substance abuse specialist.
• Monitoring:
  • Schedule follow-up appointments to monitor treatment response, adjust medications as needed, and address any emerging concerns.

Sample Answer

Comprehensive Psychiatric Evaluation

Patient: [Patient Name] Date of Birth: [Date of Birth] Date of Evaluation: [Date of Evaluation] Examiner: [Your Name]

I. Identifying Information

• Age: 35 years old
• Sex: Male
• Race/Ethnicity: African American
• Marital Status: [Marital Status]
• Occupation: [Occupation]
• Education: [Education Level]
• Referral Source: [Referral Source]

II. Chief Complaint

"Trouble sleeping for the past 3 months."

III. History of Present Illness

The patient is a 35-year-old African American male who presents with insomnia for the past 3 months. He reports difficulty both falling asleep and maintaining sleep. He describes increased difficulty falling asleep and frequent awakenings throughout the night.

To improve sleep, the patient has increased his alcohol consumption, consuming 1-2 beers nightly before bed. He reports a history of depression that was successfully treated with Prozac for 4 years. He discontinued medication 24 months ago. He rates his current depressive symptoms as 1-2 on a 10-point scale (10 being the worst). He denies suicidal ideation, homicidal ideation, or auditory/visual hallucinations.

The patient reports increased anxiety when experiencing poor sleep. He describes feeling fidgety, restless, and impaired concentration during the day.

IV. Past Psychiatric History

• History of Depression: Treated with Prozac for 4 years with successful remission.
• No history of mania, hypomania, psychosis, or other significant mental health disorders.
• No history of self-harm or suicide attempts.
• No prior hospitalizations for mental health concerns.
• No history of psychotherapy.
• No history of substance abuse treatment.