Comprehensive psychiatric evaluation and patient case presentation

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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.

To Prepare

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

NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template

CC (chief complaint):

HPI:

Past Psychiatric History:

· General Statement:

· Caregivers (if applicable):

· Hospitalizations:

· Medication trials:

· Psychotherapy or Previous Psychiatric Diagnosis:

Substance Current Use and History:

Family Psychiatric/Substance Use History:

Psychosocial History:

Medical History:

· Current Medications:

· Allergies:

· Reproductive Hx:

ROS:

· GENERAL:

· HEENT:

· SKIN:

· CARDIOVASCULAR:

· RESPIRATORY:

· GASTROINTESTINAL:

· GENITOURINARY:

· NEUROLOGICAL:

· MUSCULOSKELETAL:

· HEMATOLOGIC:

· LYMPHATICS:

· ENDOCRINOLOGIC:

Physical exam: if applicable

Diagnostic results:

Assessment

Mental Status Examination:

Differential Diagnoses:

Reflections:

References

© 2020 Walden University

Page 1 of 3

Chief compliant(CC) Joshua’s hyperactive and attentional difficulties have been exhibited both at school and at home.

HISTORY: Joshua is a Hispanic or Latino 10-year-old boy. This evaluation was requested because

mother is worried about patient’s aggressive behavior toward his younger brother and ADHD

symptoms. Mother report that patient was diagnosed at age 6 by pediatrician with ADHD,

medication was started at that time (mother unable to remember name) until age 9. Mother stopped

administering medication because it caused decrease appetite, insomnia and weight loss. Patient

is not currently taking any medication at this time.

Behavior Described In:

Symptoms/ behavior Joshua exhibits symptoms of inattention. He reports difficulty sustaining attention. His mind

wanders or he forgets. He does not seem to listen when spoken to directly. He often needs

directions repeated. Joshua is easily distracted by noises. by the radio. by other people. Joshua

needs supervision or frequent redirection. He has a short attention span.

Joshua exhibits signs of hyperactivity. He exhibits restlessness or fidgety behavior. This

behavior is evident during school hours. He tends to frequently leave his seat. He is

easily bored and changes activities frequently. Joshua ‘s excessive movement has been noted. He

is fidgety or squirms when required to sit still for a period of time. He frequently jumps or climbs.

Joshua exhibits signs of impulsive behavior. He frequently interrupts others. He often acts

in a reckless manner. He has difficulty accepting limits.

Joshua has other exhibited symptoms.

He exhibits stubborn or willful behavior.

EXAM: Joshua appears flat, inattentive, distracted, normal weight, He exhibits speech that is

normal in rate, volume, and articulation and is coherent and spontaneous. Language skills are

intact. Affect is appropriate, full range, and congruent with mood. Associations are intact and

logical. There are no apparent signs of hallucinations, delusions, bizarre behaviors, or other

indicators of psychotic process. Associations are intact, thinking is logical, and thought content

appears appropriate. Suicidal ideas or intentions are denied. Homicidal ideas or intentions are

denied. There are signs of anxiety. A short attention span is evident. Judgment appears to be

poor. Insight into problems appears to be poor. He is easily distracted. Joshua is restless. Joshua is

fidgety. There is physical hyperactivity. Joshua displayed defiant behavior during the examination.

Joshua made poor eye contact during the examination. Vocabulary and fund of knowledge indicate

cognitive functioning in the normal range. Cognitive functioning and fund of knowledge are intact

and age appropriate. Short- and long-term memory are intact, as is ability to abstract and do

Assignment 2: Comprehensive Psychiatric Evaluation and Patient 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 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.

To Prepare

Select a patient that you examined during the last 5 weeks. Review prior resources on the disorder this patient has.

It is recommended that you use the Kaltura Personal Capture tool to record and upload your assignment.

Conduct a Comprehensive Psychiatric Evaluation on this patient using the template provided in the Learning Resources. 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 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 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

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?

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