Assignment week 9 – nrnp 6635 – case study

ASSIGNMENT INSTRUCTIONS:

· Select a patient that you examined during the last 2 weeks who presented with a disorder (See attached Case study – Week # 9)

· Conduct a Comprehensive Psychiatric Evaluation on this patient and use the template provided to complete the assignment. There is also a completed exemplar document that you can see an example of the types of information a completed evaluation document should contain. ( see attached documents)

· Include at least five (5) scholarly resources to support your assessment and diagnostic reasoning.

· 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.

· 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) differentials with supporting evidence. List them from highest to lowest priority. What was your primary diagnosis and why? 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.

Reflection notes: What would you do differently in a similar patient evaluation? 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.).

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

NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template

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:

Physical exam: if applicable

Diagnostic results:

Assessment

Mental Status Examination:

Differential Diagnoses:

Reflections:

References

1

CASE STUDY 1 3

Demographics: Female, 41 years-old Hispanic on disability. The higher level of education High School.

Setting: Private Office, follow up appointed after discharged from inpatient psych admission.

Reason for and Type of Visit: “I was admitted to a mental institution for five days after I tried to kill myself taking an overdose in my medications. They discharged me from the hospital three days ago.”

Diagnosis: 

F31.64 – Bipolar disorder, current episode mixed, severe, with psychotic features

Rating Scales: BDRS – The Bipolar Depression Rating Scale: 14

History of Present Illness: 41-year-old female, Hispanic with a previous medical history of Bipolar Disorder, perceptual disturbances, and auditory hallucinations, present to this private office for an initial psychiatric evaluation and follow up after discharge from inpatient hospitalization three days ago. The patient said she complains about her treatment and medications as prescribed by her doctor. The patient said she is not feeling depressed, or having passive death wishes and is not hearing any voices currently. Patient report normal sleep (6-7 hours) and a good appetite. The patient recognized she has a history of poor medication compliance and said she wants a referral to start an outpatient program to help her with her treatment.

Psychiatric History:

The patient was in the hospital for five days after she tried to kill herself by overdose, she was discharged three days ago. The patient state she was hearing voices telling her to kill herself, and she was following the voices. The patient ingests ten pills of clonazepam belongs to her partner. The patient with long psychiatric history with multiple psychiatric admissions. The patient state she has two previous suicidal attempts by overdose and one by jumping in front of a moving car. Patient report PHP 2 years ago. She is not attending any therapy or outpatient program at this time.

Substance Abuse History: The patient report a history of substance abuse, alcohol abuse, cocaine abuse, and cannabis abuse since her 20’s. She participated and completed a voluntary rehabilitation program ten years ago, and the patient denies any substance abuse currently. UDS review form previous hospitalization is negative.

Family Psychiatric History:

Patient report that her mother had a history of bipolar disorder and Major Depressive disorder, and she kills herself by overdose when a patient was 12 years old. The patient’s sister has a Depressive Disorder.

Medical/Surgical History: The patient doesn’t have any medical or surgical history.

Medications:

The patient was discharge from impatient hospitalization with the following medications:

Klonopin 0.5mg po bid

Prozac 20mg po qam

Zyprexa 10mg po qhs

1.    KLONOPIN

Generic Name: clonazepam

Bra

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.)

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 previou

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