Assignment week 7 – nrnp 6635

Please read the complete instructions. Use the document (template) provided it to complete the assignment.

NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template

Week (enter week #): (Enter assignment title)

Student Name

College of Nursing-PMHNP, Walden University

NRNP 6635: Psychopathology and Diagnostic Reasoning

Faculty Name

Assignment Due Date

Subjective:

CC (chief complaint):

HPI:

Past Psychiatric History:

· General Statement:

· Caregivers (if applicable):

· Hospitalizations:

· Medication trials:

· Psychotherapy or Previous Psychiatric Diagnosis:

Substance Current Use and History:

Family Psychiatric/Substance Use History:

Psychosocial History:

Medical History:

· Current Medications:

· Allergies:

· Reproductive Hx:

ROS:

· GENERAL:

· HEENT:

· SKIN:

· CARDIOVASCULAR:

· RESPIRATORY:

· GASTROINTESTINAL:

· GENITOURINARY:

· NEUROLOGICAL:

· MUSCULOSKELETAL:

· HEMATOLOGIC:

· LYMPHATICS:

· ENDOCRINOLOGIC:

Objective:

Physical exam: if applicable

Diagnostic results:

Assessment:

Mental Status Examination:

Differential Diagnoses:

Reflections:

References

NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Exemplar

INSTRUCTIONS ON HOW TO USE EXEMPLAR AND TEMPLATE—READ CAREFULLY

If you are struggling with the format or remembering what to include, follow the Comprehensive Psychiatric Evaluation Template
AND
the Rubric as your guide. It is also helpful to review the rubric in detail in order not to lose points unnecessarily because you missed something required. Below highlights by category are taken directly from the grading rubric for the assignment in Weeks 4–10. After reviewing the full details of the rubric, you can use it as a guide.

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

· Read rating descriptions to see the grading standards!

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.

· Read rating descriptions to see the grading standards!

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 diagnostic criteria for each differential diagnosis and explain what DSM-5 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

.

· Read rating descriptions to see the grading standards!

Reflect on this case. Include: 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

!), 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.).

(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 demonstrat

Training Title 29

Name: Mr. Jay Feldman

Gender: male

Age:19 years old

T- 98.3 P- 69 R 16 106/72 Ht 5’7 Wt 117lbs

Background: European-American male. He has two younger brothers, one with history of

ADHD, the other with history of anxiety. His mother has anxiety; his father has paranoia

schizophrenia. He is home for spring break. He has no previous medical problems.

Developmental milestones met as child. Appetite is inconsistent and it seems he has lost 18lbs

since first going back to school in the fall. Jason has not acted this way before but did have a

short trial of aripiprazole in the last six months of high school for mild paranoia. He stopped the

medication after graduation as he could not tolerate due to side effects of akathisia. Jason has

several friends but has not kept in touch with them since being back home. He has not been

showering. Sleeping 4–5 hrs.

Symptom Media. (Producer). (2016). Training title 29 [Video]. https://video-alexanderstreetcom.ezp.waldenulibrary.org/watch/training-title-29

TRANSCRIPT OF VIDEO FILE:

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