Assignment 2: Comprehensive Psychiatric Evaluation and Patient Case Presentation
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. 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
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? Reflect on one social determinant of health according to the Healthy People 2030 (you will need to research) as applied to this case in the realm of psychiatry and mental health. As a future advanced provider, what are one health promotion activity and one patient education consideration for this patient for improving health disparities and inequities in the realm of psychiatry and mental health? Demonstrate your critical thinking.
CASE INFORMATION:
CC: “I’m trying to get my psych meds correct”.
The patient is a 53-year-old divorced, disabled white man who is homeless from Maryland and came in for an initial psychiatric evaluation. He recently was huffing between 12 to 20 cans of computer duster a day for 7 days. He reported at that time, “I wanted to die”. His longest clean period was for 2.5 years up until 2020. His identified stressors came with COVID, he was laid off from work, he was told to stay home, He stopped going to meetings, and then picked up huffing again. He denies any depressive symptoms. He feels he has enough medication in him that’s keeping him stable. He reported that he sleeps 8 to 9 hours at night when medicated. He reported that he was taking Lithium 600mg BID, Seroquel 50mg at bedtime, and Prozac 60mg daily. He reports one suicidal attempt 7 years ago with Carbon Monoxide poisoning. His girlfriend at that time found him. He denies having any current SI or HI and self-harm. He reports that he will inform staff if he has any SI or HI. He denies having any anxiety, AH, or VH. No paranoia, mood fluctuations, or irritability. There were no signs of delusions. He did report having a manic episode 3 weeks ago while huffing and is currently “riding the fumes”. He was previously dx with Bipolar I Disorder in 2013. Reports that he never had an outpatient psychiatrist. He has been in multiple psychiatric treatment centers and reports receiving his medications while in the treatment facilities. His most recent hospitalization was at DBH on 10/5/2022 before being released for care at Co Care. He grew up with both parents. They did have any psych or substance use. His brother passed away from a Fentanyl overdose.
He is divorced and disabled due to his mental health. He reports that he is financially stable with his disability income. His spirituality is of high importance. His highest level of education he received a Bachelor of Science degree in Microbiology. His family support is at a distance “they just want me to get myself together”. He has 4 daughters ages 13, 14, 17, and 19 years old and reports his relationship with his children is good. Medications include Lithium 300mg BID, Prozac 60mg daily, Seroquel 50mg qHS, Lisinopril 20mg, Claritin, and Ibuprofen. NKDA medical has HTN and B/L hip dysplasia. Vital Signs: BP- 122/78; HR- 101; RR- 18; Temp-98.9; Hgt 5’6; Wgt. 230 lbs. AAOx3 and has a steady gait with the use of a cane. The self-reported mood is “I’m riding the fumes of the mania”.
Rubric Detail
Name: NRNP_6635_Week10_Assignment_Rubric
Create documentation in the Comprehensive Psychiatric Evaluation Template about the patient you selected.
In the Subjective section, provide:
• Chief complaint
• History of present illness (HPI)
• Past psychiatric history
• Medication trials and current medications
• Psychotherapy or previous psychiatric diagnosis
• Pertinent substance use, family psychiatric/substance use, social, and medical history
• Allergies
• ROS–
Excellent 18 (18%) – 20 (20%)
The response throughly and accurately describes the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis.
In the Objective section, provide:
• Physical exam documentation of systems pertinent to the chief complaint, HPI, and history
• Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses.–
Excellent 18 (18%) – 20 (20%)
The response thoroughly and accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are thoroughly and accurately documented.
In the Assessment section, provide:
• Results of the mental status examination, presented in paragraph form.
• At least three differentials with supporting evidence. List them from top priority to least priority. Compare the DSM-5-TR diagnostic criteria for each differential diagnosis and explain what DSM-5-TR criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.–
Excellent 23 (23%) – 25 (25%)
The response thoroughly and accurately documents the results of the mental status exam.
Response lists at least three distinctly different and detailed possible disorders in order of priority for a differential diagnosis of the patient in the assigned case study, and it provides a thorough, accurate, and detailed justification for each of the disorders selected.
Reflect on this case.
Discuss what you learned and what you might do differently.
Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!),
social determinates of health, 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.).–
Excellent 9 (9%) – 10 (10%)
Reflections are thorough, thoughtful, and demonstrate critical thinking.
Provide at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support your diagnostics and differential diagnoses. Be sure they are current (no more than 5 years old).–
Excellent 14 (14%) – 15 (15%)
The response provides at least three current, evidence-based resources from the literature to support the assessment and diagnosis of the patient in the assigned case study. The resources reflect the latest clinical guidelines and provide strong justification for decision making.
Written Expression and Formatting—Paragraph development and organization:
Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused—neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria.–
Excellent 5 (5%) – 5 (5%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity.
A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria.
Written Expression and Formatting—English writing standards:
Correct grammar, mechanics, and punctuation–
Excellent 5 (5%) – 5 (5%)
Uses correct grammar, spelling, and punctuation with no errors
Total Points: 100