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 5 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
Select a patient that you examined during the last 5 weeks. Review prior resources on the disorder this patient has.
It is recommended that you use the Kaltura Personal Capture tool to record and upload your assignment.
Review the Kaltura Media Uploader resource in the left-hand navigation of the classroom for help creating your self-recorded Kaltura Personal Capture video. The Personal Capture Quickstart Guide will walk you through creating your video, uploading it to Blackboard and placing it into the assignment area.
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.
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 progress note 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?
This is the patient you can use ,Pt 1
This is a follow up visit.
Pt is a 37-year-old Hispanic American male who resides in a dorm. He has a past psychiatric history significant for diagnoses of alcohol use disorder (history of complicated withdrawal hallucinations), unspecified mood disorder, anxiety, prior suicide attempts, a history of non-suicidal self-injurious behavior, prior inpatient psychiatric hospitalizations. He has a past medical history significant for prior gastrointestinal bleed, alcoholic cirrhosis, alcoholic hepatitis, cholecystitis, and elevated liver function tests. He reports increasing depression, increasing anxiety, and symptoms of alcohol withdrawal which happened a few days ago but states that he has not alcohol since that happened and plans to stop.
Pt describes several psychosocial stressors including recent death of close friend and recent relapse into drinking due to death of said close friend, and limited support system.
Pt describes worsening mood over the past week and half. He describes symptoms of amotivation and anhedonia. He describes decreased appetite. He also describes disturbances in sleep, and states that he believes that he has insomnia. He describes feelings of hopelessness and worthlessness. Pt describes feelings of burdensomeness to friends and family. In addition to the above mentioned, patient describes worsening anxiety, specifically persistently worrying, having a hard time controlling and stopping the worrying, worrying about bad things happening. He describes auditory and visual hallucinatory experiences; he denies they are command in nature.
He denies delusions or paranoia. He denies symptoms of obsessive-compulsive disorder, or post-traumatic stress disorder. He denies homicidal ideations.
Pt states that he was unable to come to the office to get a prescription for his current meds because he felt better when he was taking them, and that after the meds ran out, he felt it was better and did not need them anymore. He stated that the recent death in his life is bringing back the old things he used to experience which is why he decided to come back for his meds.
Mental Status Exam:
Appearance and attire: appropriate level of hygiene and self-grooming
Attitude and behavior: calm, cooperative, makes fair eye contact
Speech: spontaneous, fluent, normal rate, rhythm and prosody
Affect and mood: dysphoric and restricted “I am just depressed”.
Association and thought processes: no loosening of associations, linear and goal directed in thought processes
Thought content: devoid of delusions and paranoia
Perception: did not appear to be responding to internal stimuli
Sensorium, memory, and orientation: alert and oriented to self, location, year, month, and day of the week
Intellectual functioning: based on grammar and articulation, intellectual functioning is average
Insight and judgment: fair insight; fair judgment.
Diagnosis:
Major depressive disorder, recurrent, severe, with psychotic features
Generalized anxiety disorder
Alcohol use disorder
Medications:
Continue Aripiprazole 5 mg PO daily
Lorazepam 2 mg PO prn
Continue Gabapentin 100 mg PO three times a day
Start Trazodone 100 mg at night
