Assignment 2: Comprehensive Psychiatric Evaluation and Patient Case Presentation
For this Assignment, you will document information about a patient that you examined during the last 3 weeks, using the Comprehensive Psychiatric Evaluation Template provided. You will then use this note to develop and record a case presentation for this patient. Be sure to incorporate any feedback you received on your Week 3 and Week 6 case presentations into this final presentation for the course.
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To Prepare
- Review this week’s Learning Resources and consider the insights they provide. Also review the Kaltura Media Uploader resource in the left-hand navigation of the classroom for help creating your self-recorded Kaltura video.
- Select a patient that you examined during the last 3 weeks who presented with a disorder for which you have not already conducted an evaluation in Weeks 3 or 6. (For instance, if you selected a patient with OCD in Week 6, you must choose a patient with another type of disorder for this week.) Conduct a Comprehensive Psychiatric Evaluation on this patient using the template provided in the Learning Resources. Assignment 2: Comprehensive Psychiatric Evaluation and Patient Case Presentation . There is also a completed exemplar document in the Learning Resources so that you can see an example of the types of information a completed evaluation document should contain. All psychiatric evaluations must be signed, and each page must be initialed by your Preceptor. When you submit your document, you should include the complete Comprehensive Psychiatric Evaluation as a Word document, as well as a PDF/images of each page that is initialed and signed by your Preceptor. You must submit your document using SafeAssign. Please Note: Electronic signatures are not accepted. If both files are not received by the due date, Faculty will deduct points per the Walden Late Policies.
- Then, based on your evaluation of this patient, develop a video case presentation that includes chief complaint; history of present illness; any pertinent past psychiatric, substance use, medical, social, family history; most recent mental status exam; and current psychiatric diagnosis including differentials that were ruled out.
- Include at least five (5) scholarly resources to support your assessment and diagnostic reasoning.
- Ensure that you have the appropriate lighting and equipment to record the presentation
Assignment
Record yourself presenting the complex case for your clinical patient. In your presentation:
- Dress professionally and present yourself in a professional manner.
- Display your photo ID at the start of the video when you introduce yourself.
- Ensure that you do not include any information that violates the principles of HIPAA (i.e., don’t use the patient’s name or any other identifying information). Assignment 2: Comprehensive Psychiatric Evaluation and Patient Case Presentation
- Present the full case. Include chief complaint; history of present illness; any pertinent past psychiatric, substance use, medical, social, family history; most recent mental status exam; and current psychiatric diagnosis including differentials that were ruled out.
- Report normal diagnostic results as the name of the test and “normal” (rather than specific value). Abnormal results should be reported as a specific value.
Be succinct in your presentation, and do not exceed 8 minutes. Address the following:
- Subjective: What details did the patient provide regarding their personal and medical history? What are their symptoms of concern? How long have they been experiencing them, and what is the severity? How are their symptoms impacting their functioning?
- Objective: What observations did you make during the interview and review of systems?
- Assessment: What were your differential diagnoses? Provide a minimum of three (3) possible diagnoses. List them from highest to lowest priority. What was your primary diagnosis, and why?
- Reflection notes: What would you do differently in a similar patient evaluation?
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CASE STUDY
Name KB
Age 22years
Persons Present in SessionThe patient was present in the session. The patient is not a medical decision maker and physically attended the session.
Chief Complaint
“Need a new psychiatrist”.
Started having having anxiety and depression after parents divorced. Was having difficulty
concentrating, difficulty sleeping, sad mood, multiple suicidal attempts in middle school, Mood
swings mostly around period. Admit to multiple panic attacks. Hallucinations and delusion but
thinks is related to taking hydroxyzine. Seen a therapist in when in 7th grade, psychiatrist since high. Assignment 2: Comprehensive Psychiatric Evaluation and Patient Case Presentation
school. Currently taking hydroxyzine, trazodone, paroxetine. Psychiatrist thought patient also had
bipolar but never was diagnosed and was also diagnosed with binge disorder. Having depression
years, worsened last month. More 10 lifetime episodes. Depressed most days of the week. Dry mouth and constipation
PHQ-9 (Total: 26)
GAD-7 (Total: 18)
MoodDQ (Q1 Total: 12, Q2 Total: 1, Q3 Total: 2)
The patient denied family history of bipolar disorder. The patient endorsed being diagnosed with
bipolar disorder, experiencing several of these symptoms at once, and having moderate problems
with work or social function. The patient endorsed experiencing a period of time where they were
not their usual self, with the following symptoms: having excess energy, unusual self-confidence,
decreased need for sleep, and racing thoughts, increased productivity, being unusually social and
irritable, being hyper-sexual and easily distracted, participating in risky behavior, going on spending
sprees, and experiencing pressured speech.
The patient denied experiencing: hyperactivity .
ASRS-V1.1 (Total: 56, Part A: 5, Part B: 10)
Stressors
No evidence of acute risk of harm to self or others
Suicide
paroxetine HCl (paroxetine
hcl)
RUBRIC
The student provides an accurate, clear, and complete description of the chief complaint and history of present illness.
Description of past psychiatric, substance use, medical, social, and family history
Discussion of most recent mental status exam and observations made during interview and review of systems
The student provides an accurate, clear, and complete discussion of diagnostics with results.
The student provides an accurate, clear, and complete diagnosis with three (3) differentials.
The response clearly, accurately, and thoroughly follows the Comprehensive Psychiatric Evaluation format to document the selected patient case.
NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Exemplar
(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.) Assignment 2: Comprehensive Psychiatric Evaluation and Patient Case Presentation
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. This section contains the symptoms that is bringing the patient into your office. 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 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.
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) Assignment 2: Comprehensive Psychiatric Evaluation and Patient Case Presentation
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?
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! Assignment 2: Comprehensive Psychiatric Evaluation and Patient Case Presentation
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.
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. Assignment 2: Comprehensive Psychiatric Evaluation and Patient Case Presentation
Differential Diagnoses: You must have at least three differentials with supporting evidence. Explain what rules each differential in or out and justify your primary diagnosis selection. 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!), 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
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 formatting. Assignment 2: Comprehensive Psychiatric Evaluation and Patient Case Presentation
