Week 9: Comprehensive Psychiatric Evaluation and Patient Case Presentation
*The following is the patient I will present
Problem List
1. Active – F3181 – Bipolar II disorder
2. Active – F411 – Generalized anxiety disorder
3. Active – F4312 – Post-traumatic stress disorder, chronic
4. Active – F1010 – alcohol abuse history
5. Active – F4310 – Post-traumatic stress disorder, unspecified
Patient History
Past Psychiatric History: CC: ”I’m coming back for help with psychiatric medications .”
Pt is a 39 years old female who was last seen in 2021. She stopped coming to the office and had her PCP take over managing her psychiatric medications . She has been feeling more depressed. She reports that she has a hx of depression ”my whole life.” Her upbringing was influenced by being raised by an alcoholic mother and being brought to bars and watching her mother sell herself for money. She became pregnant at a young age and her boyfriend at the time was abusive. She also had a hx of ETOH abuse, but has been sober for several years. Currently she reports sxs of racing thoughts, ”talking non-stop,” scattered thought process, tearful/emotional episodes, sleep disturbances, isolative, self-depreciating thoughts, hopelessness and helplessness. She has never been hospitalized psychiatrically. She denies HI but endorses passive SI. She denies any plans, means, or intent and is able to contract for safety. Pt is currently prescribed medication through her PCP: clonazepam 0.5mg BID. She has had previous trials with multiple SSRIs with only minimal effects.
Cc:’ I am between prescribers, leaving my PCP and in need of a psychiatrist’ Her PCP put her on Seroquel 50 mgs. She was prescribed Xanax and Clonazepam together by PCP ‘She had her PCP for about 3 years. Anxiety is high and also reports ‘I have PTSD.’ reports she isolates in her home. ‘I worry about everything.’ Endorsed irrational fears, obsession-type behaviors with a notebook where she writes lists. No current counselors. No psychiatric hospitalizations. Two DUIs in the last 15 years. One hospital detox with seizures. No SI or HI history. She is currently taking Cymbalta 30 mg PO BID from PCP for fibromyalgia. She was also recently prescribed Seroquel 50 mg PO QHS for sleep/mood..
Medical History:
- Hyperlipidemia – Active;
- Hypertension – Active
- Respiratory problems – Active
- Overactive Bladder
- Spinal stenosis – HDD
- Osteoarthritis
- Fibromyalgia
- all systems reviewed and abnormalities documented
Social History: Household Information: She lives with boyfriend. Education: college diploma, BA from a local University . Work/Employment: disabled. Marital Status: The patient has a boyfriend
Legal History:
- Type of Charges:
- Assault and Battery (drug related)
- 2 DUIs. Has her drivers license. A&B arrest was ETOH related.
Family Psychiatric History
| Mother | Brother | Sister | |
| Anxiety Disorders | X | ||
| Mood Disorders | X | ||
| Substance Abuse | X | X | X |
Family structure/Household: 5 (plus one deceased) sibling(s), 5 siblings with the client being the youngest. Father out of the picture. Mother did not remarry. All children had different fathers. Client has one adult son who is married with a son.
History of Sexual Abuse: Raped when she was 13 while in high school .
History of Physical Abuse: She was physically abused by her partner. She was physically abused by one or both parents. Mother was physically abusive and a boyfriend beat me up..
Other Trauma: One Serious car accident..
Drank heavily in her 20s when she started on the weekend and then more days heavily during the week. 2 DUIs and the medical detox at Charlton Hospital with multiple seizures while in withdrawal, all in her 20’s. Stopped drinking about 5 years ago. No other drug use reported. Wants to quit smoking.
Alcohol Use: Past history of alcohol abuse, but now sober, Quit 2012
Tobacco Use: Current smoker, patient smokes 1 pack per day, for 15 pack years
Drug Use: None.
Detox: She has attended inpatient detox for med detox.
Allergies
- LATEX
Objective
Assessment
Plan
Medications
- Risperdal 0.5 mg tablet- Dispense: 60; Refills: Two; Start Date: 01/20/2023; Sig: 1 TABLET ORAL Twice a day
- clonazepam 0.5 mg tablet- Dispense: 28; Refills: No Refills; Start Date: 01/20/2023; Sig: 1 TABLET ORAL Twice a day *
COMPREHENSIVE PSYCHIATRIC EVALUATION AND PATIENT CASE PRESENTATION, DOCUMENTATION
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.
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. Also review the Kaltura Media resources in the Classroom Support Center (accessed via the Help button).
- 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 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.
- 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.
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.
*please the following Template
Week (enter week #): (Enter assignment title)
Student Name
College of Nursing-PMHNP, Walden University
NRNP 6635: Psychopathology and Diagnostic Reasoning
Faculty Name
Assignment Due Date
© 2020 Walden University Page 2 of 3
NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template
CC (chief complaint):
HPI:
Past Psychiatric History:
ï‚· General Statement:
ï‚· Caregivers (if applicable):
ï‚· Hospitalizations:
ï‚· Medication trials:
ï‚· Psychotherapy or Previous Psychiatric Diagnosis:
Substance Current Use and History:
Family Psychiatric/Substance Use History:
Psychosocial History:
Medical History:
ï‚· Current Medications:
ï‚· Allergies:
ï‚· Reproductive Hx:
ROS:
ï‚· GENERAL:
ï‚· HEENT:
ï‚· SKIN:
ï‚· CARDIOVASCULAR:
ï‚· RESPIRATORY:
ï‚· GASTROINTESTINAL:
ï‚· GENITOURINARY:
ï‚· NEUROLOGICAL:
ï‚· MUSCULOSKELETAL:
ï‚· HEMATOLOGIC:
ï‚· LYMPHATICS:
ï‚· ENDOCRINOLOGIC:
Physical exam: if applicable
Diagnostic results:
© 2020 Walden University Page 3 of 3
Assessment
Mental Status Examination:
Differential Diagnoses:
Reflections:
References
