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 5 and Week 7 case presentations into this final presentation for the course.
ASSIGNMENT QUESTION
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.
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.
· 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:
· 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 th
Rubric Detail
Select Grid View or List View to change the rubric’s layout.
Content
Name: PRAC_6635_Week9_Assignment2_Rubric
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| Photo ID display and professional attire |
Points: Points Range: Photo ID is displayed. The student is dressed professionally. Feedback: |
Points: Points Range: Feedback: |
Points: Points Range: Feedback: |
Points: Points Range: Photo ID is not displayed. Student must remedy this before grade is posted. The student is not dressed professionally. Feedback: |
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| Time |
Points: Points Range: The video does not exceed the 8-minute time limit. Feedback: |
Points: Points Range: Feedback: |
Points: Points Range: Feedback: |
Points: Points Range: The video exceeds the 8-minute time limit. (Note: Information presented after the 8 minutes will not be evaluated for grade inclusion.) Feedback: |
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| Description of chief complaint and history of present illness |
Points: Points Range: The student provides an accurate, clear, and complete description of the chief complaint and history of present illness. Feedback: |
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 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 © 2020 Walden University Page 1 of 3 PLEASE FOLLOW THE INSTRUCTIONS AS INDICATED BELOW: 1). ZERO (0) PLAGIARISM. 2). AT LEAST 5 REFERENCES, NO MORE THAN 5 YEARS (WITHIN 5YRS, OR LESS THAN 5YRS) 3). PLEASE SEE THE ATTACHED RUBRIC DETAILS, Comprehensive Psychiatric Evaluation Exemplar, Comprehensive Psychiatric Evaluation Template, Patient History Report, Assignment question. Feedback from weeks 5 & 7 to be incooperated into this assignment. 4). Please review and follow the grading rubric details, and include each component in the assignment as required. Also, follow the APA 7 writing rules and style/Format. Thank you. Week 5: Comprehensive Psychiatric Evaluation And Patient Case Presentation Catherine Nwosu Master of Science in Nursing, Walden University NRNP 6635-24 Dr. Tabitha Perrigo September 1, 2021 Comprehensive Psychiatric Evaluation And Patient Case Presentation Stress and pressure that individuals face from circumstances such as their jobs or homes can have significant effects on their mental health (English et al., 2018). This pressure may become overwhelming and increase the risk of an individual developing a mental health problem (English et al., 2018). The pressure can result in other effects such as sleep disturbances or difficulty in eating which are also indications of underlying mental health problems (English et al., 2018). The purpose of this paper is to conduct a comprehensive psychiatric evaluation based on a patient under similar circumstances. The paper will discuss objective, subjective, assessment, and reflection notes data. CC (chief complaint): “I have lots of pressure at home and at work”. HPI: The patient is a 41-year- old Hispanic female presenting for initial evaluation with complaints of having lots of pressure at home and at work. The patient explains that she does not feel very good and even though she tries to concentrate at work, she never gets enough sleep and barely eats much. The patient explained that she has mood fluctuations with her mood going up and down causing her to sometimes cry herself to sleep. She explains that this is an issue that she has struggled with for some time now but does not give the specific duration. The patient is currently taking Mirtazapine 15 MG oral tablet daily at bedtime. She explains that she does not smoke nor does she abuse any other substance and her past medical history includes mood issues. She is married although her husband still resides in Mexico and she currently lives in the state of Maryland. There is no report of a history of trauma and she denies any suicidal or © 2020 Walden University Page 2 of 11 Tabitha Perrigo DNP PMHNP
At the top of your HPI even though this is an initial evaluation with you obviously this patient has a previous diagnosis in history you would want to begin your HPI with patient presents today for an initial evaluation with this provider but carries a diagnosis of depression that she started medication for one year ago two years ago however long that he is re-organize your HPI and write it in chronological order. When the symptoms first began if there’s a diagnosis if there’s medication what symptoms are currently going on what order did they present h
Week 7: Comprehensive Psychiatric Evaluation And Patient Case Presentation Catherine Nwosu Master of Science in Nursing, Walden University NRNP 6635-24: Psychopathology and Diagnostic Reasoning Dr. Tabitha Perrigo October 17, 2021 Comprehensive Psychiatric Evaluation And Patient Case Presentation Schizophrenia refers to a serious mental health disorder in which individuals have problems interpreting reality in a normal way (McCutcheon et al., 2019). Schizophrenia involves a mix of delusions, hallucinations, and extreme disordered thinking and behavior that can impact the daily functioning of an individual. Individuals with Schizophrenia often require lifelong treatment because the disorder impacts their ability to think, feel, and behave clearly (McCutcheon et al., 2019). It is difficult to identify a specific cause of Schizophrenia although it is believed to result from a combination of genetics, altered brain chemistry and structure, and environmental causes (Fond et al., 2021). Characteristics of Schizophrenia include thoughts or experiences that seem to be out of touch with reality and reduced participation in daily activities. Treatment for Schizophrenia often works by combining several strategies as psychotherapy, medications, and coordinated specialty care services (Fond et al., 2021). Schizophrenia falls under psychotic disorders and it affects less than 1% of individuals in the United States (Fond et al., 2021). Conducting a comprehensive evaluation during the assessment and diagnosis of patients with Schizophrenia is important to pinpoint the exact factors that point to Schizophrenia as the primary diagnosis. This paper is aimed at constructing a comprehensive psychiatric evaluation that comprises of differential diagnosis and reflection notes about a patient who is presenting with symptoms of Schizophrenia. CC (chief complaint): ” I have lots of issues at work and it is stressing me out.” HPI: The patient is a 39-year-old female who presents to the clinic via telehealth with consent obtained complaints of having lots of issues at work which stress her out. The © 2020 Walden University Page 2 of 10 Tabitha Perrigo DNP PMHNP
Good clear chief complaint
patient explains that she is currently seeing a new psychiatrist because her previous provider does not accept health insurance anymore. The patient explains that she has a history of a past diagnosis of Schizophrenia in 2018 after having an episode. She explains that the job she h PATIENT EVALUATION SUBJECTIVE OBJECTIVE
ASSESSMENT Ms. AL is a 32 years old Caucasian female seen today for initial evaluation via video conference with consent obtained with a diagnosis of bipolar disorder and depressive disorder. She reported that she needs help and that she has no motivation to live. The patient’s appearance is neat and clean. She reported that she is currently taking Trileptal 600mg and Mirtazapine 15mg. She reported that she was admitted to a psychiatric facility two different times during her teenage life. She reported that she sees and talks to a therapist once a week at the mental health clinic due to the severity of her depression. She reported that she Rubric DetailA rubric lists grading criteria that instructors use to evaluate student work. Your instructor linked a rubric to this item and made it available to you. Select Grid View or List View to change the rubric’s layout. Contenthttps%3A%2F%2Fclass.waldenu.edu%2Fwebapps%2Frubric%2FWEB-INF%2Fjsp%2Fcourse%2FrubricGradingPopup.jsp%3Fmode%3Dgrid%26isPopup%3Dtrue%26rubricCount%3D1%26prefix%3D_24499271_1%26course_id%3D_16878913_1%26maxValue%3D100.0%26rubricId%3D_2612274_1%26viewOnly%3Dtrue%26displayGrades%3Dtrue%26type%3Dgrading%26rubricAssoId%3D_3419853_1 Name: PRAC_6635_Week7_Assignment2_Rubric
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