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Assignment 2: Comprehensive Psychiatric Evaluation and Patient Case Presentation

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Comprehensive psychiatric evaluations are a way to reflect on your practicum experiences and connect the experiences to the learning you gain from your weekly Learning Resources. Comprehensive notes, such as the ones required in this practicum course, are often used in clinical settings to document patient care.

For this Assignment, you will document information about a patient that you examined during the last 5 weeks, using the Comprehensive Psychiatric Evaluation Template provided. You will then use this note to develop and record a case presentation for this patient.

To Prepare

· Select a patient that you examined during the last 5 weeks. Review prior resources on the disorder this patient has. Also review the Kaltura Media Uploader resource in the left-hand navigation of the classroom for help creating your self-recorded Kaltura video.

· Conduct a Comprehensive Psychiatric Evaluation on this patient using the template provided in the Learning Resources. 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.

· Develop a video case presentation, based on your progress note of this patient, 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 with a lab coat 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).

· 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?

By Day 7

Submit your Video and Comprehensive Psychiatric Evaluation. You must submit two (2) files for the evaluation, including a Word document and scanned PDF/images of each page that is initialed and signed by your Preceptor.

Learning Resources

 

Required Readings (click to expand/reduce)

 

 

HSoft Corporation. (2020). Meditrek: Home. https://edu.meditrek.com/Default.html  Note: Use this website to log into Meditrek to report your clinical hours and patient encounters.

HYPERLINK “https://class.content.laureate.net/1e563a49109e04e68af6cce117ed2d58.doc” \o “Comprehensive Psychiatric Evaluation Template”

Document: Comprehensive Psychiatric Evaluation Template (Word document)

HYPERLINK “https://class.content.laureate.net/feb2627c3a7610b39580d603c1c9a879.doc” \o “Comprehensive Psychiatric Evaluation Exemplar”

Document: Comprehensive Psychiatric Evaluation Exemplar (Word document)

 

Recommended Resources

 

American Psychiatric Association. (2013). Disruptive, impulse-control, and conduct disorders. In Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author. doi:10.1176/appi.books.9780890425596.dsm15

 

 

American Psychiatric Association. (2013). Dissociative disorders. In Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author. doi:10.1176/appi.books.9780890425596.dsm08

 

 

American Psychiatric Association. (2013). Somatic symptom and related disorders. In Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author. doi:10.1176/appi.books.9780890425596.dsm09

 

Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan and Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry (11th ed.). Wolters Kluwer.

· Chapter 12, “Dissociative Disorders”

· Chapter 13, “Psychosomatic Medicine”

· Chapter 19, “Disruptive, Impulse-Control, and Conduct Disorders”

· Chapter 31, “Child Psychiatry”

· Section 31.13, “Anxiety Disorders of Infancy, Childhood, and Adolescence”

· Section 31.14, “Obsessive-Compulsive Disorder in Childhood and Adolescence”

 

Walden University. (2020). College of Nursing practicum manual: Master of science in nursing (MSN) and post-master’s certificate programs. https://academicguides.waldenu.edu/fieldexperience/son/formsanddocuments

HYPERLINK “https://academicguides.waldenu.edu/fieldexperience/son/home” \o “College of Nursing” \t “_blank”

Walden University Field Experience. (2020a). Field experience: College of Nursing. https://academicguides.waldenu.edu/fieldexperience/son/home

HYPERLINK “https://academicguides.waldenu.edu/StudentPracticum/NP_StudentOrientation” \o “Student practicum resources: NP student ” \t “_blank”

Walden University Field Experience. (2020b). Student practicum resources: NP student orientation. https://academicguides.waldenu.edu/StudentPracticum/NP_StudentOrientation

 

 

CASE STUDY

M C 32 YEAR OLD FEMALE WITH DEPRESSION, ANXIETY, AND PTSD

ZOLOFT 20MG PO QD

ALPRAZOLAM 0.5MG PO TID PRN

ABILIFY 5MG PO QD

PRAZOSIN 5MG PO QHS

TRAZODONE 100MG PO QHS

AMBIEN 10MG PO QHS PRN

SHE HAD A GOOD JOB AND WAS LAID OFF AND BECAME DEPRESSED

MOOD/AFFECT- SAD AND DEPRESSED

DAD NOT DOING WELL

MOM IS ALIVE AND WELL

SIBLINGS ONE BRO AND SIS

COPING SKILLS- WALKING AND EXERCISING FOR 1 HOUR, TALKING TO MOM AND COUNSELOR.

WITHDRAWN FROM FRIENDS

NOT MARRIED BUT HAS A BOYFRIEND

SLEEP- DIFFICULTY SLEEPING TAKES AMBIEM MOST TIMES

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