PRAC 6635 WEEK 7 Comprehensive Psychiatric Evaluation and Patient, Video Case Presentation
NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template
CC (chief complaint): “I am having much trouble because I feel stuck in the wrong body.”
HPI: L.F., a 29-year-old male patient, came to the clinic expressing significant distress, stating that he feels misaligned with his assigned male gender and has been experiencing pain and difficulties as a result. He describes a sensation of being confined in an incongruous body since youth. He asserts that these emotions have escalated recently, resulting in heightened worry, sadness, and social disengagement. Despite a background of sorrow and anxiety, he lives alone and has little family assistance. He is investigating gender dysphoria and is seeking help to examine his gender identity and possible transition alternatives. He refutes any suicidal thoughts but admits to experiencing feelings of hopelessness sometimes.
Past Psychiatric History:
- General Statement: The patient claims that his issues with gender identity are the reason for his history of depression and anxiety.
- Caregivers (if applicable): None
- Hospitalizations: None
- Medication trials: The patient previously used fluoxetine for anxiety and depression but ceased its use owing to adverse consequences.
- Psychotherapy or Previous Psychiatric Diagnosis: The patient has been in therapy sporadically over the previous several years for depression and anxiety; however, he has just lately begun to address his gender dysphoria.
Substance Current Use and History: The patient indicates infrequent alcohol use, often 1 to 2 drinks weekly. He denies any prior history of drug misuse or dependency.
Family Psychiatric/Substance Use History: The patient’s mother has a history of depression, while his father has a history of addiction to alcohol. No family members are known to have a history of gender dysphoria.
Psychosocial History: The patient is now engaged as an IT professional. He lives independently and has a supportive circle of friends, although he has not revealed his issues with gender identification to them. He has a hard connection with his family, who have conservative views and may not embrace his gender identification. The patient is unmarried and has not engaged in a prolonged romantic engagement.
Medical History:
- Current Medications: None
- Allergies: No allergies documented.
- Reproductive Hx: The patient is biologically male and is childless. He has not engaged in sexual activity in the last year, owing to his gender dysphoria.
ROS:
- GENERAL: Expresses feelings of anxiety and depression. Denies recent fluctuations in weight, no fever, no weariness.
- HEENT: denies headaches, no alterations in vision, no auditory impairment, no pharyngitis.
- SKIN: denies the presence of rashes, pruritus, or alterations in skin texture.
- CARDIOVASCULAR: denies angina, no arrhythmias, no swelling.
- RESPIRATORY: denies dyspnea, no cough, no wheezing.
- GASTROINTESTINAL: denies experiencing nausea, vomiting, diarrhea, or constipation.
- GENITOURINARY: denies dysuria, no hematuria, and no alterations in urine frequency.
- NEUROLOGICAL: denies dizziness, seizures, numbness, or tingling.
- MUSCULOSKELETAL: denies arthralgia, no myopathy, no lumbago.
- HAEMATOLOGIC: denies easy bruising, lacks a history of anemia, and has no bleeding issues.
- LYMPHATICS: denies lymphadenopathy, no prior occurrence of enlarged lymph nodes.
- ENDOCRINOLOGIC: denies polyuria, polydipsia, or heat or cold sensitivity.
Physical exam:
Vital Signs: BP 120/81; T 98.3; RR 17; OS 98.5%; P 79; Ht. 5’9; Wt. 197
- GENERAL: Alert and orientated, exhibits anxiety but is not in extreme discomfort.
- HEENT: The head is normocephalic and atraumatic. The pupils are equal and round and reactive to light and accommodation. Extraocular movements are intact, and there are no oropharyngeal lesions present.
- SKIN: No sores or rashes, warm and dry.
- CARDIOVASCULAR: The heart exhibits a regular rate and rhythm, with no Gallops, rubs, or murmurs present.
- RESPIRATORY: Auscultation reveals clear lung fields bilaterally, with no presence of wheezes, rales, or rhonchi.
- GENITOURINARY: External male genitalia is normal, with no lumps or soreness present.
- NEUROLOGICAL: Neurological examination reveals intact cranial nerves II-XII, absence of focal impairments, and a normal gait.
Diagnostic results: None
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Assessment
Mental Status Examination: The 29-year-old male patient presents as well-groomed and casually attired. He demonstrates cooperative behavior, maintains eye contact, and communicates normally. The individual exhibits anxiety and depression, characterized by a constricted affect. His cognitive approach is systematic and purpose-oriented, concentrating on matters of gender identity. His cognitive functions are attentive and orientated to person, place, and time. He possesses a strong understanding of his condition and treatment requirements. Both his long-term and short-term memory is intact. He denies hallucinations or delusions. He denies any suicidal thoughts but acknowledges experiencing feelings of hopelessness at times.
Differential Diagnoses:
- Gender Dysphoria: Gender dysphoria refers to the distress or agony felt by people whose gender identity does not align with the sex they were given at birth or their sexuality-related physical characteristics (Collet et al., 2021). The patient satisfies the DSM-5 criteria for gender dysphoria, which is defined as a marked discordance between the gender that is experienced or expressed and the gender that is assigned. This difference must persist for a minimum of six months and result in considerable difficulty or decline in social, occupational, or other critical areas of functioning.
- Major Depressive Disorder: The symptoms of MDD encompass a persistently low mood, anhedonia, feelings of shame or inadequacy fatigue, impaired concentration, alterations in appetite, psychomotor agitation or retardation, sleep disturbances, and suicidal ideation (Dwyer et al., 2020). The patient expresses symptoms of sadness and social isolation, which are prevalent in MDD. These symptoms seem to be a consequence of his gender dysphoria rather than a core depressive disease.
- Generalized Anxiety Disorder: GAD is a mental health illness marked by pervasive apprehension, worry, and a continual feeling of being overwhelmed (Sapra et al., 2020). It is characterized by excessive, persistent, and illogical preoccupation with everyday issues (Van Der Grinten et al., 2020). The patient exhibits considerable worry about his gender identification and the possible social repercussions of transitioning. Anxiety is evident, although it is more strongly associated with his gender dysphoria than with a generalized anxiety illness.
Reflections: In a comparable patient interaction, I would emphasize improved cultural competency by comprehensively grasping the patient’s cultural background and its influence on their experience of gender dysphoria. I would do thorough history-taking to investigate the patient’s psychological background, including support networks and experiences of prejudice. Timely multidisciplinary engagement with mental health specialists and social workers is crucial for developing a customized treatment plan (De Blok et al., 2021). I would use proven screening instruments to evaluate the patient’s mental health requirements precisely. Furthermore, I would emphasize the social determinants of health, including the impacts of prejudice and stigma, while promoting access to support groups to mitigate isolation. Finally, informing the patient about mental health options would enable them to pursue assistance, enhancing their overall well-being (Cooper et al., 2020).
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
Collet, S., Bhaduri, S., Kiyar, M., T’Sjoen, G., Mueller, S., & Guillamon, A. (2021). Characterization of the 1H-MRS Metabolite Spectra in Transgender Men with Gender Dysphoria and Cisgender People. Journal of Clinical Medicine, 10(12), 2623. https://doi.org/10.3390/jcm10122623
Cooper, K., Russell, A., Mandy, W., & Butler, C. (2020). The phenomenology of gender dysphoria in adults: A systematic review and meta-synthesis. Clinical Psychology Review, 80, 101875. https://doi.org/10.1016/j.cpr.2020.101875
De Blok, C. J., Wiepjes, C. M., Van Velzen, D. M., Staphorsius, A. S., Nota, N. M., Gooren, L. J., Kreukels, B. P., & Heijer, M. D. (2021). Mortality trends over five decades in adult transgender people receiving hormone treatment: a report from the Amsterdam cohort of gender dysphoria. The Lancet Diabetes & Endocrinology, 9(10), 663–670. https://doi.org/10.1016/s2213-8587(21)00185-6
Dwyer, J. B., Aftab, A., Radhakrishnan, R., Widge, A., Rodriguez, C. I., Carpenter, L. L., Nemeroff, C. B., McDonald, W. M., & Kalin, N. H. (2020). Hormonal Treatments for major depressive Disorder: state of the art. American Journal of Psychiatry, 177(8), 686–705. https://doi.org/10.1176/appi.ajp.2020.19080848
Sapra, A., Bhandari, P., Sharma, S., Chanpura, T., & Lopp, L. (2020). I am using Generalized Anxiety Disorder-2 (GAD-2) and GAD-7 in a primary care setting. Cureus. https://doi.org/10.7759/cureus.8224
Van Der Grinten, H. C.-., Verhaak, C., Steensma, T., Middelberg, T., Roeffen, J., & Klink, D. (2020). Gender incongruence and gender dysphoria in childhood and adolescence—current insights in diagnostics, management, and follow-up. European Journal of Pediatrics, 180(5), 1349–1357. https://doi.org/10.1007/s00431-020-03906-y
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Comprehensive Psychiatric Evaluation and Patient, Video 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 2 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.
To Prepare
- Review this week’s Learning Resources and consider the insights they provide about assessment and diagnosis. Also review the Kaltura Media resource in the Classroom Support Center (accessed via the Help button).
- Select a patient that you examined during the last 2 weeks who presented with a disorder other than the one present in your selected case for Week 5.
- 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 by your Preceptor. When you submit your document, you should include the complete Comprehensive Psychiatric Evaluation as a Word document and the completed assignment 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 evaluation 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 Video Case Presentation.
Note: In Week 7: Assignment 2, Part 2 you will the Comprehensive Psychiatric Evaluation including two (2) files for the evaluation, including a Word document and scanned PDF/images of the completed assignment signed by your Preceptor.
submission information
- Click on Start Assignment near the top of the page.
- Next, click Text Entry and then click the Embed Kaltura Media button.
- Select your recorded video under My Media.
- Check the box for the End-User License Agreement and select Submit Assignment for review.
Rubric
PRAC_6635_Week7_Assignment2_Part1__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 OutcomeDescription of chief complaint and history of present illness |
|
5 pts | ||||
| This criterion is linked to a Learning OutcomeDescription of past psychiatric, substance use, medical, social, and family history |
|
5 pts | ||||
| This criterion is linked to a Learning OutcomeDiscussion of most recent mental status exam and observations made during interview and review of systems |
|
15 pts | ||||
| This criterion is linked to a Learning OutcomeDiscussion of diagnostics with results |
|
10 pts | ||||
| This criterion is linked to a Learning OutcomeDiagnostic Impression with three (3) differential diagnosesReflection on this case |
|
25 pts | ||||
| This criterion is linked to a Learning OutcomePresentation style |
|
5 pts | ||||
| Total Points: 75 | ||||||