PRAC 6635 WEEK 5 Comprehensive Psychiatric Evaluation and Patient Case Presentation, Video Case Presentation
NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template
Subjective:
CC (chief complaint): “I have persistent anxiety and depression.”
HPI: F.R., a male patient who was 57 years old, presented himself at the clinic, expressing his dissatisfaction with the fact that he had been suffering constant symptoms of worry and despair for the last six months. He talks about how he never stops worrying, has trouble sleeping, and has lost interest in hobbies that he used to take pleasure in. In addition, he states that he is experiencing weariness and having trouble focusing. However, the patient agrees that there are occasions when they feel hopeless, but they deny having any suicidal thoughts. Even though he is already taking medicine for diabetes and hypertension, he claims that he is not currently utilizing any medication for this mental disease.
Past Psychiatric History:
- General Statement: The patient has a history of generalized anxiety disorder and severe depressive illness, diagnosed eight years before. He has intermittently used numerous drugs but has not maintained consistency with follow-up sessions.
- Caregivers (if applicable): Parent
- Hospitalizations: He denies ever being hospitalized.
- Medication trials: The patient indicates that he was prescribed fluoxetine for the treatment of depression and anxiety disorder, although he has not adhered to a steady regimen of this medication.
- Psychotherapy or Previous Psychiatric Diagnosis: The patient acknowledges a history of anxiety problems and depressive illness from 8 years before and has intermittently engaged in cognitive behavioral treatment.
Substance Current Use and History: He smokes one pack of cigarettes a day, drinks beer sometimes to increase his energy, and says he has never used narcotics or other illicit substances.
Family Psychiatric/Substance Use History: The patient claims not to be aware of his family’s psychiatric issues.
Psychosocial History: The patient receives financial assistance from his younger sister, with whom he cohabitates. His job had concluded around three years before. His latest educational achievement is the 12th grade. He asserts that he consumes three meals each day. He contends that he tries to exercise consistently but has been notably sluggish lately, citing fatigue throughout the day.
Medical History: Hypertension with Type 2 Diabetes Mellitus.
- Current Medications: Metformin 500 mg twice a day, Lisinopril 10 mg once daily.
- Allergies: There were no recorded medication allergies.
- Reproductive Hx: The patient is childless and heterosexual. The patient’s family does not have any history of reproductive illnesses or fertility issues.
ROS:
- GENERAL: denies experiencing fever, chills, recent fluctuations in body weight, gastrointestinal disturbances, or diminished appetite.
- HEENT: Head: not injured. Eyes: denies using corrective lenses, reports no decreased vision, and has no redness or irritation. Nose: denies nasal bleeding, irritations, sinus problems, congestion, or inflammation. Throat and Mouth: denies gingival hemorrhage, odynophagia, or dysphagia.
- SKIN: denies the presence of blisters, wounds, hives, or rashes.
- CARDIOVASCULAR: denies any previous instances of cyanosis or uncomfortable murmurs. Denies experiencing palpitations or soreness in the chest.
- RESPIRATORY: denies any history of coughing up blood, wheezing, dyspnea, pneumonia, bronchitis, or bloody cough.
- GASTROINTESTINAL: No symptoms of constipation, diarrhea, emesis, bloating, or altered bowel habits are present.
- GENITOURINARY: rejects changes in the frequency of urination, dysuria, reluctance to urinate, or nocturnal enuresis.
- NEUROLOGICAL: denies paranesthesia, nausea, vomiting, loss of consciousness, syncope, and dizziness.
- MUSCULOSKELETAL: denies any joint pain or soreness. There is no sign of joint edema. Confirms both the lower and upper extremities’ whole range of motion.
- HAEMATOLOGIC: denies problems with hemorrhaging or protracted wound healing.
- LYMPHATICS: negates signs of lymphadenopathy.
- ENDOCRINOLOGIC: Denies excessive thirst, increased appetite, and frequent urination. Not exhibiting symptoms of hypothyroidism.
Objective:
Physical exam: Vital Signs: BP 139/80; P 97; R 19; T 98.7 O2 98.9% Ht 5’8, Wt. 189 lbs.
Diagnostic results: A comprehensive hemogram, TSH assessment, LFTs, kidney function test, and toxicology screenings were conducted; the findings indicated a reduced level of ethanol.
Assessment:
Mental Status Examination: The patient is well-groomed and attired for the weather. He has a cooperative but anxious demeanor characterized by ordinary speech and tone. His mood is characterized by anxiety and despondency, accompanied by a restricted affect. His cognitive approach is rational and purpose-driven, with apprehensions over health and financial security. He has awake and orientated cognition, although he exhibits inadequate attention and focus. He has excellent perception and is seeking assistance. His judgment remains intact, enabling them to make sound judgments about everyday activities and health.
Differential Diagnoses:
- Generalized anxiety disorder: GAD is a mental health illness marked by chronic and disproportionate apprehension over several facets of everyday life (Papola et al., 2023). The DSM-5-TR delineates specific criteria for diagnosing generalized anxiety disorder, including excessive worry and stress, difficulty in self-regulation, and a minimum of three physical or mental symptoms, including irritability, tiredness, restlessness, edginess, and sleep disturbances (Byrd-Bredbenner et al., 2021). The patient reports a history of anxiety disorder for the past eight years.
- Major depressive disorder: MDD, sometimes referred to as depression, is a mental health disease marked by enduring melancholy or lack of interest in external stimuli, adversely affecting everyday activities such as sleep, eating, and work (Amiri, 2021). The DSM-5 criteria for diagnosing depression require the presence of at least five signs over two weeks, including a depressed mood, diminished interest or pleasure, significant weight loss, cognitive slowing, fatigue, feelings of worthlessness, impaired concentration, and recurrent suicidal ideation (Gutiérrez-Rojas et al., 2020). The patient reports losing his job three years ago, resulting in persistent depression and lethargy.
- Bipolar II Disorder: The DSM-5 diagnostic criteria for Bipolar II Disorder need the occurrence of at least one hypomanic episode and a severe depressive episode, excluding any manic episodes (Baldessarini et al., 2020). A hypomanic episode is characterized by a sustained elevated or irritable mood lasting a minimum of four consecutive days, accompanied by three or more of the following symptoms: inflated self-esteem, reduced need for sleep, excessive talkativeness, racing thoughts, heightened distractibility, increased goal-directed activity, and excessive engagement in activities with detrimental outcomes. The incident must be clear, atypical, and discernible. The patient reported being depressed for the past six months but does not qualify for this diagnosis.
Reflections: In a comparable patient evaluation, I would thoroughly examine the patient’s social support network and daily activities to pinpoint relevant stresses and intervention opportunities. I would use standardized screening instruments such as the PHQ-9 and GAD-7 to assess symptom intensity and track progress. Considering the social determinant of health, “Social and Community Context,” from HealthyPeople 2030, I acknowledge that the patient’s restricted social connections and isolated living conditions may intensify his anxiety and sadness (Watts et al., 2020). To mitigate health disparities, I would establish a community-oriented mental health program encompassing group therapy and social activities to cultivate connections while educating patients on the significance of sustaining social relationships and community engagement for improved mental health outcomes.
PRECEPTOR VERIFICATION:
I confirm that the patient used for this assignment was seen and managed by the student at their Meditrek-approved clinical site during this quarter’s learning course.
Preceptor signature: ________________________________________________________
Date: ________________________
References
Amiri, S. (2021). Unemployment associated with major depression disorder and depressive symptoms: a systematic review and meta-analysis. International Journal of Occupational Safety and Ergonomics, 28(4), 2080–2092. https://doi.org/10.1080/10803548.2021.1954793
Baldessarini, R. J., Vázquez, G. H., & Tondo, L. (2020). Bipolar depression: a major unsolved challenge. International Journal of Bipolar Disorders, 8(1). https://doi.org/10.1186/s40345-019-0160-1
Byrd-Bredbenner, C., Eck, K., & Quick, V. (2021). GAD-7, GAD-2, and GAD-mini: Psychometric properties and norms of university students in the United States. General Hospital Psychiatry, 69, 61–66. https://doi.org/10.1016/j.genhosppsych.2021.01.002
Gutiérrez-Rojas, L., Porras-Segovia, A., Dunne, H., Andrade-González, N., & Cervilla, J. A. (2020). Prevalence and correlates of major depressive disorder: a systematic review. Brazilian Journal of Psychiatry, 42(6), 657–672. https://doi.org/10.1590/1516-4446-2020-0650
Papola, D., Miguel, C., Mazzaglia, M., Franco, P., Tedeschi, F., Romero, S. A., Patel, A. R., Ostuzzi, G., Gastaldon, C., Karyotaki, E., Harrer, M., Purgato, M., Sijbrandij, M., Patel, V., Furukawa, T. A., Cuijpers, P., & Barbui, C. (2023). Psychotherapies for generalized anxiety disorder in adults. JAMA Psychiatry, 81(3), 250. https://doi.org/10.1001/jamapsychiatry.2023.3971
Watts, S., Marchand, A., Bouchard, S., Gosselin, P., Langlois, F., Belleville, G., & Dugas, M. J. (2020). Tele psychotherapy for generalized anxiety disorder: Impact on the working alliance. Journal of Psychotherapy Integration, 30(2), 208–225. https://doi.org/10.1037/int0000223
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Comprehensive Psychiatric Evaluation and Patient Case Presentation, Documentation
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.
Resources
Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.
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To Prepare
- Select a patient that you examined during the last 5 weeks. Review prior resources on the disorder this patient has.
- In Week 5: Assignment 2, Part 1, you submitted the Video Evaluation Presentation.
- In Week 5: Assignment 2, Part 2, you will submit the documentation.
- 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. You will submit your document in Week 5 Assignment, Part 2 area and you will 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 Turn It In. 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 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.
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.
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? 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.
By Day 7
Submit your Comprehensive Psychiatric Evaluation documentation, including a Word document and scanned PDF/images of each page that is initialed and signed by your Preceptor.
Note: In Week 5: Assignment 2, Part 1 you will submit the Video Evaluation Presentation.
submission information
Before submitting your final assignment, you can check your draft for authenticity. To check your draft, access the Turnitin Drafts from the Start Here area.
- To submit your completed assignment, save your Assignment as WK5Assgn2_LastName_Firstinitial
- Then, click on Start Assignment near the top of the page.
- Next, click on Upload File and select Submit Assignment for review.
Rubric
PRAC_6635_Week5_Assignment2_Part2_Rubric
| Criteria | Ratings | Pts | ||||
|---|---|---|---|---|---|---|
| This criterion is linked to a Learning OutcomeComprehensive Psychiatric Evaluation documentation |
|
25 pts | ||||
| Total Points: 25 | ||||||