What would you do differently in a similar patient evaluation?
Assignment 2: Comprehensive Psychiatric Evaluation and Patient Case Presentation
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. 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.
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:
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
Patient and his parents present. Reason for therapy is family concerns about the problem their son (patient, presents at home. Patient was asked about the problems he knows he exhibits at home.
Patient unable to verbalize any information at the moment. The APN asked the parents to step out the room, who quietly left the session room.
Patient keeps shaking his legs nearly the entire length of the session. He chose to narrate how his life has been since he left High school. States he was more in school during his college years than being at home. As a result, he had little issues with his parents, states most of the behavioral and interpersonal problems he is currently experiencing with them are because he lives with them. He mentions the stress on him is mostly from interacting with them. Patient states he has had many physical assaults with his father. Patient is not explaining the reasons those physical assaults were happening nor how they happened but is, saying “may be I’m in a bad mood”
Pt’s diagnosis is Attention-deficit hyperactivity disorder, predominantly inattentive type, F90.0 (ICD-10) (Active)
Meds:
Alprazolam 0.5 mg PO Daily PRN anxiety
Trazodone 50 mg PO 1/2 QHS
Depakote 250 mg PO BID
Clomipramine 50mg PO QHS
Learning Resources
Required Readings (click to expand/reduce)
Carlat, D. J. (2017). The psychiatric interview (4th ed.). Wolters Kluwer.
Chapter 31, “Assessing Personality Disorders”
Chapter 32, “How to Educate Your Patient”
HSoft Corporation. (2020). Meditrek: Home. https://edu.meditrek.com/Default.html
Note: Use this website to log into Meditrek to report your clinical hours and patient encounters.
Document: Comprehensive Psychiatric Evaluation Template (Word document)
Document: Comprehensive Psychiatric Evaluation Exemplar (Word document)
Recommended
American Psychiatric Association. (2013). Sexual dysfunctions. In Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
American Psychiatric Association. (2013). Personality disorders. In Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author. doi:10.1176/appi.books.9780890425596.dsm18
American Psychiatric Association. (2013). Paraphilic disorders. In Diagnostic and statistical manual of mental disorders (5th ed., pp. 685–706). Author.
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 17, “Human Sexuality and Sexual Dysfunction”
Chapter 22, “Personality Disorders”
