What observations did you make during the interview and review of systems? 

Assignment 2: Comprehensive Psychiatric Evaluation and Patient Case Presentation

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 2 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

  • Review this week’s Learning Resources and consider the insights they provide about assessment and diagnosis. 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 2 weeks who presented with a disorder other than the one present in your selected case for Week 5.
  • 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 evaluation 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 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?

 

About patient to use

Pt is a 45 yr old pt who was referred to the office by another patient. Pt wants a second opinion on the diagnosis that was given to him by his psychiatrist. He stated that he has issues with anxiety, has difficulty completing tasks, thinking clearly, and difficulty focusing/reading. He states that he sometimes gets panic attacks. Pt has dentures(full) in the upper area, He also complains of back pain. Pt was instructed by the doctor not to tell us what his diagnosis was.

Pt currently takes Zoloft 50mg, Gabapentin 800mg, Motrin 800mg prn. Pt states that he worries a lot about his life/death. Has difficulty sleeping but states that he takes trazodone 50mg. Denise any history of suicide attempts.

Dx: ADD(pt was given an ADD questionnaire to complete hence the diagnosis), GAD

Meds: Adderall 10mg BID morning and 2pm

Alprazolam 1mg once daily

Duloxetine (Cymbalta) 30mg BID

Continue Zoloft 50mg

Gabapentin 300mg 1 in morning and 2 caps at night.

A week supply of meds. Wil follow up with patient next week.

Learning Resources

Required Readings (click to expand/reduce)

 

Carlat, D. J. (2017). The psychiatric interview (4th ed.). Wolters Kluwer.

  • Chapter 27, “Assessing Psychotic Disorders”

 

Recommended:

American  Psychiatric Association. (2013). Medication-induced movement disorders and other adverse effects of medication. In Diagnostic and statistical manual of mental disorders (5th ed., pp. 709–714). Author.

 

American Psychiatric Association. (2013). Schizophrenia spectrum and other psychotic disorders. In Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author. doi:10.1176/appi.books.9780890425596.dsm02

 

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 7, “Schizophrenia Spectrum and Other Psychotic Disorders”
  • Chapter 29, “Psychopharmacological Treatment”
    • Section 29.2, “Medication Induced-Movement Disorders”
  • Chapter 31, “Child Psychiatry”
    • Section 31.15, “Early-Onset Schizophrenia”

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

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

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