PRAC 6645 WK 4 Comprehensive Psychiatric Evaluation Note and Patient Case Presentation, Part 1

PRAC 6645 WK 4 Comprehensive Psychiatric Evaluation Note and Patient Case Presentation, Part 1

Subjective:

CC (chief complaint): ” I am worried about my temper outbursts.”

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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

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  • 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:

 

  1. 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).
  2. 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

 

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Comprehensive Psychiatric Evaluation Note and Patient Case Presentation, Part 1

Psychiatric notes are a way to reflect on your practicum experiences and connect them to the didactic learning you gain from your NRNP courses. 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 in a group setting during the last 4 weeks, 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

 

Learning Resources

Required Readings

Required Media

To Prepare

  • Review this week’s Learning Resources and consider the insights they provide about clinical practice guidelines.
  • Select a group patient for whom you conducted psychotherapy for a mood disorderduring the last 4 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 by your Preceptor. When you submit your note, you should include the complete comprehensive psychiatric evaluation note as a Word document and pdf/images the completed assignment signed by your Preceptor. You must submit your note using Turnitin.
    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 Kalturasupport resources in the Classroom Support Center found by clicking on the Help
  • 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.

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.

By Day 7

Submit your Video and Comprehensive Psychiatric Evaluation Note. You must submit two files for the evaluation note, including a Word document and scanned pdf/images the completed assignment signed by your Preceptor.

submission information – Part 1: Recording

To submit your video response entry:

  1. Click on Start Assignment near the top of the page.
  2. Next, click Text Entry and then click the Embed Kaltura Media button.
  3. Select your recorded video under My Media.
  4. Check the box for the End-User License Agreement and select Submit Assignment for review.

submission information – Part 2: Comprehensive Psychiatric Evaluation Note

To submit Part 2 of this Assignment, click on the following link:

Rubric

PRAC_6645_Week4_Assignment2_PT1_Rubric

PRAC_6645_Week4_Assignment2_PT1_Rubric
Criteria Ratings Pts
This criterion is linked to a Learning OutcomePhoto ID display and professional attire 5 to >0.0 ptsExcellentPhoto ID is displayed. The student is dressed professionally.

0 ptsFair

0 ptsGood

0 ptsPoorPhoto ID is not displayed. Student must remedy this before grade is posted. The student is not dressed professionally.

 5 pts
This criterion is linked to a Learning OutcomeTime 5 to >3.0 ptsExcellentThe video does not exceed the 8-minute time limit.

3 to >0.0 ptsGoodThe video exceeds the 8-minute time limit. (Note: Information presented after 8 minutes will not be evaluated for grade inclusion.)

0 ptsFair

0 ptsPoor

 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 to >8.0 ptsExcellentThe video accurately and concisely presents the patient’s subjective complaint, history of present illness, medications, psychotherapy or previous psychiatric diagnosis, and pertinent histories and/or review of systems that would inform a differential diagnosis.

8 to >7.0 ptsGoodThe video accurately presents the patient’s subjective complaint, history of present illness, medications, psychotherapy or previous psychiatric diagnosis, and pertinent histories and/or review of systems that would inform a differential diagnosis.

7 to >6.0 ptsFairThe video presents the patient’s subjective complaint, history of present illness, medications, psychotherapy or previous psychiatric diagnosis, and pertinent histories and/or review of systems that would inform a differential diagnosis, but is somewhat vague or contains minor inaccuracies.

6 to >0 ptsPoorThe video presents an incomplete, inaccurate, or unnecessarily detailed/verbose description of the patient’s subjective complaint, history of present illness, medications, psychotherapy or previous psychiatric diagnosis, and pertinent histories and/or review of systems that would inform a differential diagnosis. Or subjective documentation is missing.

 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 to >8.0 ptsExcellentThe video accurately and concisely documents the patient’s physical exam for pertinent systems. Pertinent diagnostic tests and their results are documented, as applicable.

8 to >7.0 ptsGoodThe response accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are documented, as applicable.

7 to >6.0 ptsFairDocumentation of the patient’s physical exam is somewhat vague or contains minor inaccuracies. Diagnostic tests and their results are documented but contain inaccuracies.

6 to >0 ptsPoorThe response provides incomplete, inaccurate, or unnecessarily detailed/verbose documentation of the patient’s physical exam. Systems may have been unnecessarily reviewed, or objective documentation is missing.

 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 to >17.0 ptsExcellentThe video accurately documents the results of the mental status exam…. Video presents at least three differentials in order of priority for a differential diagnosis of the patient, and a rationale for their selection. Response justifies the primary diagnosis and how it aligns with DSM-5 criteria.

17 to >15.0 ptsGoodThe video adequately documents the results of the mental status exam…. Video presents three differentials for the patient and a rationale for their selection. Response adequately justifies the primary diagnosis and how it aligns with DSM-5 criteria.

15 to >13.0 ptsFairThe video presents the results of the mental status exam, with some vagueness or inaccuracy…. Video presents three differentials for the patient and a rationale for their selection. Response somewhat vaguely justifies the primary diagnosis and how it aligns with DSM-5 criteria.

13 to >0 ptsPoorThe response provides an incomplete, inaccurate, or unnecessarily detailed/verbose description of the results of the mental status exam and explanation of the differential diagnoses. Or assessment documentation is missing.

 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 to >17.0 ptsExcellentThe video clearly and concisely outlines an evidence-based treatment plan for the patient that addresses treatment modality, psychotherapy choice with framework principles, and rationale. … Discussion includes a clear and concise follow-up plan and parameters…. The discussion includes a clear and concise referral plan.

17 to >15.0 ptsGoodThe video clearly outlines an appropriate treatment plan without evidence-based discussion for the patient that addresses treatment modality, psychotherapy choice with framework principles, and rationale. … Discussion includes a clear follow-up plan and parameters…. The discussion includes a clear referral plan.

15 to >13.0 ptsFairThe response somewhat vaguely or inaccurately outlines a treatment plan for the patient and provides a rationale for the treatment approaches recommended…. The discussion is somewhat vague or inaccurate regarding the follow-up plan and parameters…. The discussion is somewhat vague or inaccurate regarding a referral plan.

13 to >0 ptsPoorThe response does not address the treatment plan or the treatment plan is not appropriate for the assessment and the diagnosis or is missing elements of the treatment plan. … There is no discussion for follow-up and parameters. … There is no discussion of a referral plan.

 20 pts
This criterion is linked to a Learning OutcomePresentation style 5 to >4.0 ptsExcellentPresentation style is exceptionally clear, professional, and focused.

4 to >3.5 ptsGoodPresentation style is clear, professional, and focused.

3.5 to >2.0 ptsFairPresentation style is mostly clear, professional, and focused.

2 to >0 ptsPoorPresentation style is unclear, unprofessional, and/or unfocused.

 5 pts

Total Points: 75

 

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