Assignment 2: Comprehensive Psychiatric Evaluation and Patient Case Presentation<\/p>\n
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.
\nTo Prepare
\n\u2022\tReview 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.
\n\u2022\tSelect 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. 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.
\n\u2022\tThen, 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.
\n\u2022\tInclude at least five (5) scholarly resources to support your assessment and diagnostic reasoning.
\n\u2022\tEnsure that you have the appropriate lighting and equipment to record the presentation
\nAssignment
\nRecord yourself presenting the complex case for your clinical patient. In your presentation:
\n\u2022\tDress professionally and present yourself in a professional manner.
\n\u2022\tDisplay your photo ID at the start of the video when you introduce yourself.
\n\u2022\tEnsure that you do not include any information that violates the principles of HIPAA (i.e., don\u2019t use the patient\u2019s name or any other identifying information).
\n\u2022\tPresent 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.
\n\u2022\tReport normal diagnostic results as the name of the test and \u201cnormal\u201d (rather than specific value). Abnormal results should be reported as a specific value.
\nBe succinct in your presentation, and do not exceed 8 minutes. Address the following:
\n\u2022\tSubjective: 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?
\n\u2022\tObjective: What observations did you make during the interview and review of systems?
\n\u2022\tAssessment: 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?
\n\u2022\tReflection notes: What would you do differently in a similar patient evaluation?<\/p>\n
CASE STUDY
\nName KB
\nAge 22years
\nPersons Present in SessionThe patient was present in the session. The patient is not a medical decision maker and physically attended the session.
\nChief Complaint
\n“Need a new psychiatrist”.
\nStarted having having anxiety and depression after parents divorced. Was having difficulty
\nconcentrating, difficulty sleeping, sad mood, multiple suicidal attempts in middle school, Mood
\nswings mostly around period. Admit to multiple panic attacks. Hallucinations and delusion but
\nthinks is related to taking hydroxyzine. Seen a therapist in when in 7th grade, psychiatrist since high
\nschool. Currently taking hydroxyzine, trazodone, paroxetine. Psychiatrist thought patient also had
\nbipolar but never was diagnosed and was also diagnosed with binge disorder. Having depression
\nyears, worsened last month. More 10 lifetime episodes. Depressed most days of the week. Dry mouth and constipation
\nPHQ-9 (Total: 26)
\nGAD-7 (Total: 18)
\nMoodDQ (Q1 Total: 12, Q2 Total: 1, Q3 Total: 2)
\nThe patient denied family history of bipolar disorder. The patient endorsed being diagnosed with
\nbipolar disorder, experiencing several of these symptoms at once, and having moderate problems
\nwith work or social function. The patient endorsed experiencing a period of time where they were
\nnot their usual self, with the following symptoms: having excess energy, unusual self-confidence,
\ndecreased need for sleep, and racing thoughts, increased productivity, being unusually social and
\nirritable, being hyper-sexual and easily distracted, participating in risky behavior, going on spending
\nsprees, and experiencing pressured speech.
\nThe patient denied experiencing: hyperactivity .
\nASRS-V1.1 (Total: 56, Part A: 5, Part B: 10)
\nStressors
\nNo evidence of acute risk of harm to self or others
\nSuicide
\nparoxetine HCl (paroxetine
\nhcl)<\/p>\n
RUBRIC
\nThe student provides an accurate, clear, and complete description of the chief complaint and history of present illness.
\nDescription of past psychiatric, substance use, medical, social, and family history
\nAssignment help – Discussion of most recent mental status exam and observations made during interview and review of systems
\nThe student provides an accurate, clear, and complete discussion of diagnostics with results.
\nThe student provides an accurate, clear, and complete diagnosis with three (3) differentials.
\nThe response clearly, accurately, and thoroughly follows the Comprehensive Psychiatric Evaluation format to document the selected patient case.<\/p>\n","protected":false},"excerpt":{"rendered":"
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