COMPREHENSIVE PSYCHIATRIC EVALUATION NOTE AND PATIENT CASE PRESENTATION, PART 1 PRAC 6645
Sample Answer for COMPREHENSIVE PSYCHIATRIC EVALUATION NOTE AND PATIENT CASE PRESENTATION, PART 1 PRAC 6645 Included After Question
Psychiatric notes are a way to reflect on your practicum experiences and connect the experiences to the learning you gain from your weekly Learning Resources. Comprehensive psychiatric evaluation 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 at your practicum site, using the Comprehensive Psychiatric Evaluation Note Template provided. You will then use this note to develop and record a case presentation for this patient.
RESOURCES
Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.
WEEKLY RESOURCES
TO PREPARE
- Review this week’s Learning Resources and consider the insights they provide about impulse-control and conduct disorders.
- Select a patient for whom you conducted psychotherapy for an impulse control or conduct disorder during the last 6 weeks. Create a Comprehensive Psychiatric Evaluation Note on this patient using the template provided in the Learning Resources. There is also a completed template provided as an exemplar and guide. All psychiatric evaluation notes must be signed, and each page must be initialed by your Preceptor. When you submit your note, you should include the complete comprehensive evaluation note as a Word document and pdf/images of each page that is initialed and signed by your Preceptor. You must submit your note 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 Grading Policy. - Then, based on your evaluation of this patient, develop a video presentation of the case. Plan your presentation using the Assignment rubric and rehearse what you plan to say. Be sure to review the Kaltura Media Uploader resource in the left-hand navigation of the classroom for help creating your self-recorded Kaltura video.
- Include at least five scholarly resources to support your assessment and diagnostic reasoning.
- Ensure that you have the appropriate lighting and equipment to record the presentation.
THE ASSIGNMENT
Record yourself presenting the complex case for your clinical patient.
Do not sit and read your written evaluation! The video portion of the assignment is a simulation to demonstrate your ability to succinctly and effectively present a complex case to a colleague for a case consultation. The written portion of this assignment is a simulation for you to demonstrate to the faculty your ability to document the complex case as you would in an electronic medical record. The written portion of the assignment will be used as a guide for faculty to review your video to determine if you are omitting pertinent information or including non-essential information during your case staffing consultation video.
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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 complex case study. Be succinct in your presentation, and do not exceed 8 minutes. Include subjective and objective data; assessment from most recent mental status exam; current psychiatric diagnosis including differentials that were ruled out; current psychotherapeutic plan (include one health promotion activity and one patient education strategy you provided); and patient progress toward treatment goals.
- Subjective:What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What was the duration and severity of their symptoms? How are their symptoms impacting their functioning in life?
- Objective:What observations did you make during the psychiatric assessment?
- Assessment:Discuss the patient’s mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses in order of highest to lowest priority and explain why you chose them. What was your primary diagnosis and why? Describe how your primary diagnosis aligns with DSM-5-TR diagnostic criteria and is supported by the patient’s symptoms.
- Plan:Describe your treatment modality and your plan for psychotherapy. Explain the principles of psychotherapy that underline your chosen treatment plan to support your rationale for the chosen psychotherapy framework. What were your follow-up plan and parameters? What referrals would you make or recommend as a result of this psychotherapy session?
- Reflection notes:What would you do differently in a similar patient evaluation? Reflect on one social determinant of health according to the HealthyPeople 2030 (you will need to research) as applied to this case in the realm of psychiatry and mental health. As a future advanced provider, what are one health promotion activity and one patient education consideration for this patient for improving health disparities and inequities in the realm of psychiatry and mental health? Demonstrate your critical thinking.
COMPREHENSIVE PSYCHIATRIC EVALUATION NOTE AND PATIENT CASE PRESENTATION, PART 1 PRAC 6645
BY DAY 7
Submit your Video and Comprehensive Psychiatric Evaluation Note Assignment. You must submit two files for the evaluation note, including a Word document and scanned pdf/images of each page that is initialed and signed by your Preceptor.
SUBMISSION INFORMATION – PART 1: RECORDING
To submit your video response entry:
- Click on Start Assignmentnear the top of the page.
- Next, click Text Entryand then click the Embed Kaltura Media
- Select your recorded video under My Media.
- Check the box for the End-User License Agreement and select Submit Assignmentfor review.
SUBMISSION INFORMATION – PART 2: COMPREHENSIVE PSYCHIATRIC EVALUATION NOTE
To submit Part 2 of this Assignment, click on the following link:
Week 7 Assignment 2, Part 2
A Sample Answer For the Assignment: COMPREHENSIVE PSYCHIATRIC EVALUATION NOTE AND PATIENT CASE PRESENTATION, PART 1 PRAC 6645
Title: COMPREHENSIVE PSYCHIATRIC EVALUATION NOTE AND PATIENT CASE PRESENTATION, PART 1 PRAC 6645
Subjective:
CC (chief complaint): ” I am worried about my temper outbursts.”
HPI: S.A is a thirty-five-year-old male patient who visited the facility seeking help with his temper. He has been consistently having temper outbursts and finds it hard to control his temper. He indicated that he had observed a pattern with his temper problem since they came seasonally. He has observed for the last few years, and he suspects that there could be an underlying problem that needs to be solved. The period is accompanied by other undesirable symptoms such as the inability to keep friends, getting bored easily, and finding it hard to concentrate. His concentration becomes so low that he even misses meeting some deadlines which have been set. He also experiences problems with sleep and finds it difficult to sleep and maintain sleep. The patient has also been anxious in the last few days; however, he can’t specify what could be causing the anxiety. Another aspect that makes him worried is that he also gains weight, and he fears that he may become unhealthy and obese.
(include psychiatric ROS rule out)
Past Psychiatric History:
- General Statement: The patient presents to the clinic for the first time, having experienced the symptoms for two years in a row
- Caregivers (if applicable): the patient lives with his partner, who is also his caregiver
- Hospitalizations: the patient has no significant history of hospitalizations
- Medication trials: There are no records of medication trials
- Psychotherapy or Previous Psychiatric Diagnosis: The patient had been diagnosed with anxiety before and has been managing the same through psychotherapy
Substance Current Use and History: The patient denies any use of substances or alcohol currently. However, he consumed alcohol some years ago but stopped.
Family Psychiatric/Substance Use History: The patient’s father was a heavy alcohol consumer and attended detox programs for management. The mother was diagnosed with depression after his father’s death and had been managing the condition using medication and psychotherapy.
Psychosocial History: the patient was born and raised in Minneapolis. He lived with his parents until he married and moved into their house, where he lives together with his wife and one child. He has two other siblings, an elder brother, and a younger sister. The patient is married with one child, a daughter. He has a college degree, and he is currently working as a sales representative of a local manufacturing company. The patient has no significant legal history; however, he was once charged with causing discord in public. The patient has no trauma or violence history.
Medical History: The patient has no current illnesses, no past surgery, head injuries, or seizures
- Current Medications: There are no current medications used by the patient
- Allergies: No known food, medication, or environmental allergies
- Reproductive Hx: The patient is in a heterosexual relationship, sexually active, and currently has one child with his partner
- GENERAL: The patient is calm but looks anxious
- HEENT: The head is normal. No eye infection, double vision, double vision, or visual loss. No ear infections or hearing loss. No nose congestion or sneezing. No sore throat
- SKIN: no rashes, itchiness, or irritation
- CARDIOVASCULAR: No chest discomfort, pressure, or pain was reported
- RESPIRATORY: No congestion, no breathing problems
- GASTROINTESTINAL: no eating disorders, no abdominal ailments
- GENITOURINARY: no pain passing urine, no urge for frequent urination
- NEUROLOGICAL: The patient reports being worried about his lack of temper control and anxious
- MUSCULOSKELETAL: No glutes, no muscle or back pain
- HEMATOLOGIC: No blood infections were reported
- LYMPHATICS: No swelling was noted
- ENDOCRINOLOGIC: has no abnormal sweating or excessive thirst
Objective:
Vitals: T- 97.7, P- 87, R -20, BP- 115/80, Ht- 5’8, Wt-130 lbs.
Physical exam: if applicable
Diagnostic results: none was conducted
Objective:
Diagnostic results:
Assessment:
Mental Status Examination: The patient is a thirty-five-year-old white patient. The patient was appropriately dressed and well-groomed. He was able to maintain eye contact. The patient’s speech is fluent but appears rushed and pressured. The patient’s mood is sad. He is also irritable; the patient denies suicidal thoughts, ideation, or action; he also denies the intention of harming others or self-harm. The patient is, however, delusional. The patient has a coherent thought process. He has problems with concentrating and rarely concentrates during the assessment.
Differential Diagnoses:
- Intermittent explosive Disorder: Intermittent explosive disorder is a psychiatric condition where a patient has various symptoms, including repeated sudden episodes of angry verbal outbursts and violent, aggressive, or impulsive behavior. In most cases, such reactions are usually out of proportion to the situation (McCloskey et al.,2019). The patient has reported episodes of anger outbursts which he has experienced at a similar time of the year. He also has problems with keeping friends, getting bored easily, and finding it hard to concentrate. His concentration becomes so low that he even misses meeting some deadlines which have been set. He also experiences problems with sleep and finds it difficult to sleep and maintain sleep. Based on the DSM-V diagnostic criteria, this patient’s most likely diagnosis is intermittent explosive disorder (Fariba & Gokarakonda, 2020).
- Generalized Anxiety disorder: This is a type of anxiety disorder in which a patient presents with various symptoms which may be similar to those of obsessive-compulsive disorder and panic disorder (Crocq, 2022). The patient may present with symptoms such as trouble with concentration, restlessness, and constant worry. The patient reported trouble with concentration and an inability to meet his deadlines. As such, this is a likely diagnosis.
- Hypochondriasis: This is another condition where a patient presents with symptoms such as intense fear of having a serious condition and worry that minor symptoms may be a sign of something serious (Syaukat, 2022). A patient may also present with other symptoms, such as panic attacks and anxiety. The patient displayed anxiety symptoms which also makes this condition a possibility.
Reflections:
I agree with the preceptor’s assessment and diagnostic impression of the patient. This is because the diagnostic impression was based on the DSM-V diagnostic criteria. This case presented a chance to learn about psychiatric assessment and more about impulse-control and conduct disorders. For example, most of these disorders have more than one similar or the same symptoms (Frick & Matlasz, 2018). Therefore, it is important for a mental health specialist to pay adequate attention to come up with the correct diagnosis.
Case Formulation and Treatment Plan:
From the symptoms reported by the patient and those observed, the most likely diagnosis is intermittent explosive disorder. Therefore, the patient needs an appropriate management approach. Even though various medications exist that can be used as treatment, such as anticonvulsant mood stabilizers and selective serotonin reuptake (Coccaro & Lee,2019), the first line of treatment chosen for this case is psychotherapy. The patient should commence cognitive behavioral therapy weekly (Hewage et al.,2018). As such, he has been referred to a psychotherapist. In addition, the patient needs to visit the facility after four weeks for a review of his progress. Generalized anxiety disorder and hypochondriasis should also be managed by a similar approach.
References
Coccaro, E. F., & Lee, R. J. (2019). 5‐HT2c agonist, lorcaserin, reduces aggressive responding in intermittent explosive disorder: A pilot study. Human Psychopharmacology: Clinical and Experimental, 34(6), e2714. https://doi.org/10.1002/hup.2714
Crocq, M. A. (2022). The History of generalized anxiety disorder as a diagnostic category. Dialogues In Clinical Neuroscience. https://doi.org/10.31887/DCNS.2017.19.2/macrocq
Fariba, K., & Gokarakonda, S. B. (2020). Impulse control disorders. https://www.ncbi.nlm.nih.gov/books/NBK562279/
Frick, P. J., & Matlasz, T. M. (2018). Disruptive, impulse-control, and conduct disorders. In Developmental pathways to disruptive, impulse-control and conduct disorders (pp. 3-20). Academic Press. https://doi.org/10.1016/B978-0-12-811323-3.00001-8
Hewage, K., Steel, Z., Mohsin, M., Tay, A. K., De Oliveira, J. C., Da Piedade, M., … & Silove, D. (2018). A wait-list controlled study of a trauma-focused cognitive behavioral treatment for intermittent explosive disorder in Timor-Leste. American Journal of Orthopsychiatry, 88(3), 282. https://psycnet.apa.org/doi/10.1037/ort0000280
McCloskey, M. S., Fahlgren, M. K., & Coccaro, E. F. (2019). Assessment and treatment of intermittent explosive disorder. Aggression: Clinical Features and Treatment Across the Diagnostic Spectrum, 31–49.
Syaukat, A. (2022). Hypochondriasis: A Literature Review. Scientia Psychiatrica, 3(1), 220–226. https://doi.org/10.37275/scipsy.v3i1.85
PRAC_6645_Week7_Assignment2_Pt1_Rubric
| PRAC_6645_Week7_Assignment2_Pt1_Rubric | ||||||
| Criteria | Ratings | Pts | ||||
| This criterion is linked to a Learning OutcomePhoto ID display and professional attire |
|
5 pts | ||||
| This criterion is linked to a Learning OutcomeTime |
|
5 pts | ||||
| This criterion is linked to a Learning OutcomeDiscuss Subjective data:• Chief complaint• History of present illness (HPI)• Medications• Psychotherapy or previous psychiatric diagnosis• Pertinent histories and/or ROS |
|
10 pts | ||||
| This criterion is linked to a Learning OutcomeDiscuss Objective data:• Physical exam documentation of systems pertinent to the chief complaint, HPI, and history• Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses |
|
10 pts | ||||
| This criterion is linked to a Learning OutcomeDiscuss results of Assessment:• Results of the mental status examination• Provide a minimum of three possible diagnoses in order of highest to lowest priority and explain why you chose them. What was your primary diagnosis and why? Describe how your primary diagnosis aligns with DSM-5 diagnostic criteria and is supported by the patient’s symptoms. |
|
20 pts | ||||
| This criterion is linked to a Learning OutcomeDiscuss treatment Plan:• A treatment plan for the patient that addresses psychotherapy and rationales including a plan for follow-up parameters and referrals |
|
20 pts | ||||
| This criterion is linked to a Learning OutcomePresentation style |
|
5 pts | ||||
| Total Points: 75 | ||||||
As we begin this session, I would like to take this opportunity to clarify my expectations for this course:
Please note that GCU Online weeks run from Thursday (Day 1) through Wednesday (Day 7).
Course Room Etiquette:
- It is my expectation that all learners will respect the thoughts and ideas presented in the discussions.
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Late Policy and Grading Policy
Discussion questions:
- I do not mark off for late DQ’s.
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- Depending upon the amount, severity, and frequency of the plagiarism that is committed, students may receive in-class penalties that range from coaching (for a minor omission), -20% grade penalties for resubmission, or zero credit for a specific assignment. University-level penalties may also occur, including suspension or even expulsion from the University.
- If you are at all uncertain about what constitutes plagiarism, you should review the resources available in the Student Success Center. Also, please review the University’s policies about plagiarism which are covered in more detail in the GCU Catalog and the Student Handbook.
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LopesWrite
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Grade of Incomplete
- The final grade of Incomplete is granted at the discretion of the instructor; however, students must meet certain specific criteria before this grade accommodation is even possible to consider.
- The grade of Incomplete is reserved for times when students experience a serious extenuating circumstance or a crisis during the last week of class which prevents the completion of course requirements before the close of the grading period. Students also must pass the course at the time the request is made.
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Grade Disputes
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- However, after we have discussed individual assignments’ point scores, if you still believe that the final grade you have earned at the end of the course is not commensurate with the quality of work you produced for this class, there is a formal Grade Grievance procedurewhich is outlined in the GCU Catalog and Student Handbook.