| Course | NR 668 Psychiatric-Mental Health Capstone Practicum & Intensive |
|---|---|
| Week | 3 |
| Paper type | Comprehensive evaluation note |
| Length | About 1,120 words, 5 pages |
| Format | APA 7 student paper |
| School | Chamberlain University |
| Program | MSN, Psychiatric-Mental Health Nurse Practitioner (PMHNP) |
| Updated | October 2026 |
Free sample paper for NR 668 Week 3
Comprehensive Evaluation Note: Initial Psychiatric Evaluation of an Adult Referred for Depression Unresponsive to Two SSRIs, With an Argued Differential and Risk Reasoning
Student Name
College of Nursing, Chamberlain University
NR 668: Psychiatric-Mental Health Capstone Practicum & Intensive
Instructor Name
Month Day, Year
Comprehensive Evaluation Note: Initial Psychiatric Evaluation of an Adult Referred for Depression Unresponsive to Two SSRIs, With an Argued Differential and Risk Reasoning
Identifying Information and Source
Adult, 34, graphic designer; household of partner and one child, age six. Referred by primary care. Sources: the patient, the partner (present for the second half with the patient's consent), the referral letter and primary care records. Evaluation date: 2 September 2026, outpatient psychiatric clinic.
Presenting Concern
Patient report: "I've been depressed for most of a year, and the pills haven't worked. Lately I can't sleep but I can't stop moving."
History of Present Illness
Patient report: low mood, loss of interest, fatigue, guilt, poor concentration and passive thoughts of death since late 2025, after a job change. Sertraline to 150 mg for three months, little change. Escitalopram 20 mg for five months, slight early improvement then loss of effect. Two weeks of sleeping about four hours, feeling "wired," irritability, two large purchases.
Partner report: at least three periods in five years of four to five days of very little sleep, high energy, rapid talk, many new projects and overspending, without hospitalization, psychosis or job loss.
Past Psychiatric History
One untreated depressive episode at about 24. No prior hospitalizations, no suicide attempts, no self-harm. No previous psychiatric care beyond primary care.
Medical History
Body mass index 31. No thyroid, neurological or cardiac disease. Primary care laboratory results: thyroid function normal, A1C 5.8%, lipids mildly raised. Medications: escitalopram 20 mg daily. No allergies.
Substance Use
Alcohol two or three drinks most evenings for a year, more during low periods; no withdrawal symptoms reported. Cannabis about twice a month for sleep. Tobacco and other drugs denied.
Family and Social History
A parent with unrecognized "mood swings"; a maternal uncle who died by suicide; a parent with type 2 diabetes. Stable relationship, one child, full-time work, financial strain from recent purchases. No legal issues. No firearms in the home, confirmed by both.
Examination
Clinician observation: casually dressed, restless, foot tapping throughout; speech slightly rapid and interruptible; affect dysphoric with irritable moments; thought process goal-directed with tangents that returned; no delusions; no hallucinations reported or observed; oriented; three of three words recalled at five minutes; partial insight; intact judgment for the interview.
Measures: PHQ-9 19. Mood Disorder Questionnaire positive (Hirschfeld et al., 2000). Columbia screen: a passive wish to be dead, with no method, intent or plan, and no attempts at any point in life (Posner et al., 2011).
Differential, Argued
Bipolar II disorder, depressive episode with mixed features. For: partner-described episodes of at least four days meeting hypomania criteria, current mixed symptoms, family history of mood disorder and suicide, nonresponse to two antidepressants. Against: the patient did not recognize the episodes, so their timing rests on one informant.
Major depressive disorder with antidepressant-induced activation. For: activation began on escitalopram. Against: hypomanic periods predate any antidepressant.
Alcohol-induced depressive disorder. For: regular drinking, worse in lows. Against: the depressive episode began before the drinking increased, and hypomania is not explained by alcohol.
Borderline personality disorder. For: irritability and impulsive spending. Against: no history of unstable relationships, self-harm or identity disturbance; mood changes last days, not hours.
Attention-deficit/hyperactivity disorder. For: distractibility. Against: no childhood history; symptoms are episodic, not lifelong.
Set aside, with reason: thyroid disease, given normal results.
Risk Assessment
Concerning: passive death wish, family history of suicide, mixed features, regular alcohol use, recent impulsivity. Protective: no prior attempts, no firearms, engaged partner, a young child the patient describes as "my reason," employment, willingness to engage in treatment. Reasoning: mixed states with alcohol raise acute risk, but the absence of intent, plan, preparation and access to a firearm, together with strong protective factors and a partner present, support outpatient care with a safety plan and close follow-up. Risk is judged moderate in the near term and to be reviewed at every visit.
Plan
Diagnosis: bipolar II disorder; the present episode is depressive, with mixed features.
Medication: taper escitalopram over one week; start quetiapine with titration to 300 mg at bedtime by day 4, first-line for bipolar II depression in the current guideline (Yatham et al., 2018). Baseline weight, waist, blood pressure; fasting glucose and lipids at 12 weeks.
Safety: safety plan written with patient and partner; 988 crisis line; medications kept by partner during titration.
Alcohol: the patient agreed to a break from drinking while the medicines change, to be reviewed in two weeks.
Psychoeducation: bipolar II disorder, the meaning of the "good weeks," early warning signs.
Therapy: referral to individual therapy; a family-focused approach considered later.
Coordination: letter to primary care the same day.
Follow-up: two weeks; telephone check at five days.
Information Still Needed
Prior records from the college counseling service, which the patient has agreed to request, to see whether the first episode was documented. A collateral call with the patient's sibling, offered and declined for now. A sleep history from the partner over the next two weeks, to confirm that sleep improves on treatment.
Consent and Capacity
The patient understood the change in diagnosis, the reasons for stopping escitalopram and the common side effects of quetiapine, including sedation, weight gain and effects on glucose and lipids, and agreed to the plan. The patient asked whether the diagnosis would appear in records sent to their employer; it would not, and this was explained.
Why the Differential Stays Open
A diagnosis of bipolar II disorder carries long-term consequences: the medications a patient will be offered, how future depressions are treated and how the patient understands their own history. It rests here on one informant's account of episodes the patient did not recognize. That is enough to act on, given the mixed features and the risk of continuing an antidepressant, but not enough to close the question. The note says so, and the next visits will test it: whether the mixed symptoms settle on treatment, whether the college records describe the first episode and whether the patient, once well, recognizes the "good weeks" in the way the partner described.
How This Note Will Be Used
As the baseline for every later visit, with the PHQ-9, the Columbia screen and weight recorded here as the starting points. The differential stays open in the next notes until the college records arrive and the response to treatment is clear.
Time and Supervision
Ninety-minute evaluation. Discussed with the supervising psychiatric nurse practitioner, who agreed with the diagnosis and plan.
References
Hirschfeld, R. M. A., Williams, J. B. W., Spitzer, R. L., Calabrese, J. R., Flynn, L., Keck, P. E., Jr., Lewis, L., McElroy, S. L., Post, R. M., Rapport, D. J., Russell, J. M., Sachs, G. S., & Zajecka, J. (2000). Development and validation of a screening instrument for bipolar spectrum disorder: The Mood Disorder Questionnaire. American Journal of Psychiatry, 157(11), 1873-1875. https://doi.org/10.1176/appi.ajp.157.11.1873
Posner, K., Brown, G. K., Stanley, B., Brent, D. A., Yershova, K. V., Oquendo, M. A., Currier, G. W., Melvin, G. A., Greenhill, L., Shen, S., & Mann, J. J. (2011). The Columbia-Suicide Severity Rating Scale: Initial validity and internal consistency findings from three multisite studies with adolescents and adults. American Journal of Psychiatry, 168(12), 1266-1277. https://doi.org/10.1176/appi.ajp.2011.10111704
Yatham, L. N., Kennedy, S. H., Parikh, S. V., Schaffer, A., Bond, D. J., Frey, B. N., Sharma, V., Goldstein, B. I., Rej, S., Beaulieu, S., Alda, M., MacQueen, G., Milev, R. V., Ravindran, A., O'Donovan, C., McIntosh, D., Lam, R. W., Vazquez, G., Kapczinski, F., . . . Berk, M. (2018). Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) 2018 guidelines for the management of patients with bipolar disorder. Bipolar Disorders, 20(2), 97-170. https://doi.org/10.1111/bdi.12609
Reading the NR 668 Week 3 instructions
Include every standard element, identifying information, presenting concern, psychiatric and medical history, substances, family and social history, risk, examination, formulation and plan, and make each one carry content rather than a placeholder line. Keep what the patient and others reported apart from what you observed. In the differential, name three or four possibilities and state the evidence for and against each, including the ones you set aside. Write risk as reasoning: the concerning and protective features and how you weighed them, not only a level. Make the plan answer the whole picture, not just the diagnosis. Record consent and the patient's questions, and say what information is still needed.
How the NR 668 Week 3 example is put together
The sample's sources are the patient, the partner, the referral and primary care records. History notes two SSRI trials, partner-described hypomania, alcohol most evenings, a family history of mood disorder and suicide and a body mass index of 31. The examination records observed restlessness, speech and thought process, with PHQ-9, screening and Columbia results. The differential weighs bipolar II disorder, antidepressant-induced activation, alcohol-induced depression, borderline personality disorder and ADHD, setting thyroid disease aside. Risk is judged moderate with reasoning. The plan covers quetiapine, safety, alcohol, education, therapy and a letter to primary care, and records information still needed. The note explains why the differential stays open and how the next visits will test it.
Where the points sit in the NR 668 Week 3 rubric
Evaluation notes lose most when standard headings are present but filled with one-line placeholders, which looks complete and says nothing. Next is a note that blends patient report with observation, so a reader cannot tell what the clinician actually saw. Many differentials list diagnoses without evidence for or against each, or omit the options set aside. Risk is often reduced to a word such as low or moderate with no reasoning. Plans that address only medication miss substances, safety, education and coordination. Notes that never record consent or the patient's understanding leave a gap a supervisor will notice. Closing the differential too early can also lock in an uncertain diagnosis. Notes that omit information still needed also present an evaluation as finished when it is not.
NR 668 Week 3 help from the desk
A comprehensive note takes time to write well, and the hard parts are the differential and the risk reasoning. A guided draft can help you fill each element with content, separate report from observation and argue the differential with evidence for and against. We can also help you write risk as reasoning and build a plan that answers the whole picture. Keeping the differential open where the evidence is thin is easier with a second reader. The evaluation is yours. We can also help you list the information still needed and how you will get it.
Get a NR 668 Week 3 example written to your instructions
Send the Week 3 instructions with the evaluation template your classroom uses, and a custom example is written into that exact template and returned inside 24 to 48 hours. The first one is free. If your section names the presentation, include it, since a complicated case is built differently from a straightforward one.
More NR 668 papers and PMHNP samples
- NR 668 Week 1: Case Selection Post
- NR 668 Week 2: Case Conference Write-Up
- NR 668 Week 4: Case Defense Write-up
- NR 668 Week 5: Panel Review Write-up
- NR 668 Week 6: Safety Decision Write-up
- NR 668 Week 7: Practice Question Brief
- NR 668 Week 8: Capstone Case Paper
- NR 546 Week 3: Medication Selection Rationale
- NR 607 Week 3: Safety Plan Write-Up
- NR 547 Week 3: Diagnostic Formulation
- NR 606 Week 3: Comorbidity Case Write-Up
NR 668 Week 3 questions, answered
How long is a comprehensive evaluation note supposed to be?
Longer than most coursework and still bounded by whatever your section states. Length here is a consequence rather than a target: a complicated presentation needs a differential with reasoning in it and a risk section that shows its working, and those take space. What does not earn space is narrative repetition, where the same history appears under three headings in slightly different words.
Can I change the template headings?
Generally no. Where a classroom supplies a documentation template, the headings are usually part of what is marked, and renaming or merging them costs points even when the content underneath is good. If a heading does not apply to your patient, the safe move is to keep it and write one line saying why, rather than deleting it and leaving a gap a grader has to interpret.
Does an evaluation note need citations?
Often fewer than students expect. Documentation is not an essay, and most sections want references only where a decision rests on a guideline or a piece of evidence, typically in the plan or the risk section. Where they are required, attaching them to the specific choice they informed reads far better than a reference list assembled at the end to satisfy a count.
Where can I find a free NR 668 Week 3 sample paper?
You can read the whole initial psychiatric evaluation note, with its argued differential and risk reasoning, right here.
Why does the NR 668 Week 3 note keep the differential open?
The diagnosis rests on one informant's account, so college records, the response to treatment and the patient's own recognition will be used to test it.