Comprehensive Psychiatric Evaluation and Patient Case Presentation

Assignment 2: Comprehensive Psychiatric Evaluation and Patient Case Presentation 
 
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.
 
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 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.

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

 
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?

SO please Summarize so that I may not exceed 8 minutes when presenting
 
Rubric Detail
 
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Name: PRAC_6635_Week9_Assignment2_Rubric

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Excellent
Good
Fair
Poor
Photo ID display and professional attire
5 (5%) – 5 (5%)
Photo ID is displayed. The student is dressed professionally.
0 (0%) – 0 (0%)
0 (0%) – 0 (0%)
0 (0%) – 0 (0%)
Photo ID is not displayed. Student must remedy this before grade is posted. The student is not dressed professionally.
Time
5 (5%) – 5 (5%)
The video does not exceed the 8-minute time limit.
0 (0%) – 0 (0%)
0 (0%) – 0 (0%)
0 (0%) – 0 (0%)
The video exceeds the 8-minute time limit. (Note: Information presented after the 8 minutes will not be evaluated for grade inclusion.)
Description of chief complaint and history of present illness
5 (5%) – 5 (5%)
The student provides an accurate, clear, and complete description of the chief complaint and history of present illness.
4 (4%) – 4 (4%)
The student provides an accurate description of the chief complaint and history of present illness.
2 (2%) – 3 (3%)
The student provides a vague, inaccurate, or incomplete description of the chief complaint and history of present illness, or description is missing.
0 (0%) – 1 (1%)
The student provides a completely inaccurate, or incomplete description of the chief complaint and history of present illness, or the description is missing.
Description of past psychiatric, substance use, medical, social, and family history
5 (5%) – 5 (5%)
The student provides an accurate, clear, and complete description of past psychiatric, substance use, medical, social, and family history.
4 (4%) – 4 (4%)
The student provides an accurate description of past psychiatric, substance use, medical, social, and family history.
2 (2%) – 3 (3%)
The student provides a vague, inaccurate, or incomplete description of psychiatric, substance use, medical, social, and family history, or description is missing.
0 (0%) – 1 (1%)
The student provides a completely inaccurate, or incomplete description of psychiatric, substance use, medical, social, and family history, or description is missing.
Discussion of most recent mental status exam and observations made during interview and review of systems
14 (14%) – 15 (15%)
The student provides an accurate, clear, and complete discussion of results from most recent mental status exam and observations made during interview and review of systems.
12 (12%) – 13 (13%)
The student provides an accurate discussion of results from most recent mental status exam and observations made during interview and review of systems.
11 (11%) – 11 (11%)
The student provides a vague, inaccurate, or incomplete discussion of results from most recent mental status exam and observations made during interview and review of systems.
0 (0%) – 10 (10%)
All or most of the discussion is inaccurate or missing.
Discussion of diagnostics with results
9 (9%) – 10 (10%)
The student provides an accurate, clear, and complete discussion of diagnostics with results.
8 (8%) – 8 (8%)
The student provides an accurate discussion of diagnostics with results.
7 (7%) – 7 (7%)
The student provides a vague, inaccurate, or incomplete discussion of diagnostics with results.
0 (0%) – 6 (6%)
All or most of the discussion is inaccurate or missing.
Diagnosis with three (3) differentials
23 (23%) – 25 (25%)
The student provides an accurate, clear, and complete diagnosis with three (3) differentials.
20 (20%) – 22 (22%)
The student provides an accurate diagnosis with three (3) differentials.
18 (18%) – 19 (19%)
The student provides a vague, inaccurate, less than 3 or incomplete diagnosis with differentials.
0 (0%) – 17 (17%)
All or most of the discussion is inaccurate or missing. Less than 2 diagnosis.
Comprehensive Psychiatric Evaluation documentation
23 (23%) – 25 (25%)
The response clearly, accurately, and thoroughly follows the Comprehensive Psychiatric Evaluation format to document the selected patient case.
20 (20%) – 22 (22%)
The response accurately follows the Comprehensive Psychiatric Evaluation format to document the selected patient case.
18 (18%) – 19 (19%)
The response follows the Comprehensive Psychiatric Evaluation format to document the selected patient case, with some vagueness and inaccuracy.
0 (0%) – 17 (17%)
The response incompletely and inaccurately follows the Comprehensive Psychiatric Evaluation format to document the selected patient case.
Presentation style
5 (5%) – 5 (5%)
Presentation style is exceptionally clear, professional, and focused.
4 (4%) – 4 (4%)
Presentation style is clear, professional, and focused.
3 (3%) – 3 (3%)
Presentation style is mostly clear, professional, and focused
0 (0%) – 2 (2%)
Presentation style is unclear, unprofessional, and/or unfocused.
 
Total Points: 100
Name: PRAC_6635_Week9_Assignment2_Rubric
 
 
Below is an example of my friend last year.
Comprehensive Psychiatric Evaluation and Patient Case Presentation
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PMHNP, Walden University
Dr. gggggggggggg
01/31/2022
 
 
 
 
 
 
 
 
 
 
 
NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template
CC (chief complaint): “My thoughts are racing and I can not concentrate”
HPI: This is a 39-year-old Caucasian female who presents today with complaints of low concentration and difficulty completing tasks. She reports having attention deficit hyperactivity disorder, major depression, and anxiety disorder. She reports the onset of this episode happened when her boyfriend died while on the phone with her.She reports a difficult history of work related issues due to her inability to stay on task. She admits part of her work issues stem from prior use of alcohol. Her current medications include Abilify, Suboxone 8-2mg Sublingual film, Wellbutrin, Vyvance, and Trintellix. She was referred to this clinic by her primary care physician for a psychiatric evaluation and treatment.
Past Psychiatric History: 
Anxiety:Started in 2002, Thinks that smoking pot triggered current high level of anxiety
Panic Attacks: Started 2002, Hearts racing, Scary thoughts, Disorientation,  Tingling in extremities
Depression: Sleeps too much, Lack of interest, Isolation.         
ADHD: Diagnosed in 5th grade, Went away then it came back.       
Sleep Disturbance Described: Trouble falling sleep.
 

General Statement: Pt entered treatment at age 5 for ADHD. She has had three inpatient rehab treatments for alcohol dependence starting at age 24 and reports no current alcohol use. She is currently being treated for opioid dependence, Cannibis use, and nicotine dependence.
Caregivers (if applicable): None/Independent
Hospitalizations: ADACT  twice in January 2019, Rehab at age 20 and 25 at Footprints and recovery Crisis centers, and Greenville detox centers
Medication trials: Adderall, Ritalin
Psychotherapy or Previous Psychiatric Diagnosis: MDD, Anxiety disorder, ADHD. Pt in individual and group therapy at RAPHA.

Substance Current Use and History: Client disclosed the following Use of Substances
Alcohol: 
            Started drinking abusively at age 21
            Stopped drinking a year ago
            Relapsed in March of last year and went to rehab
            Everything in life has gone bad bc of alcohol           
Marijuana: 
            Mother got her on pot at age 17
            She used to get her friends high
            Currently uses gummies
Nicotine: 
            A couple cigarettes a day
            Currently vapes
Cocaine:
            Abused it at parties
Pain Pills:
            Was on oxycodon and oxycontin
Heroin: 
            Was on heroin for about a month 
Benzodiazepines: 
            13 years klonipin 
            Would have seizures with it
            Starting selling it because she was given too much and she needed money
Mushrooms:   
            Did it twice
LSD:   
            Took it once
            Says it was terrible bc she was alone
Ecstasy:   
            30 times
            Thought she was going to get a hole in her brain and she quit
KRATOM: 
            Last use yesterday
            Puts her in a better mood and takes away pain 
            Pt doesnâ€t think itâ€s bad for her and states that she is not ashamed to take it
Paint/Glue/Inhalants:   
            Hand sanitizer with salt
Family Psychiatric/Substance Use History: Mother is bipolar and an alcoholic. Father committed suicide when patient was 6 years old.
Psychosocial History: The patient was born in NC and raised by her mother and step-father. Step dad raised her since she was 13 and she calls him dad, reporting he was really supportive of her. Her mom and step-dad are now divorced. Her biological father committed suicide when she was 6 years old. She is an only child. Shencurrently lives in a single family home with her mother. She reports and her mother are close She reports there are financial issues with the house and believes the house will be forclosed on. She has never been married and has no children. Her education background includes graduating from Camelot Academy in 2000. She then attended University of North Carolina, Charlotte earning a Bachelor of Arts degree with a minoe in theatre in 2004. She was a figure skater in high school. Her hobbies include exercising and making crafts. Work history includes work in retail at malls and department stores Walgreens and Food Lion. Dairy Queen longest job for 2 years, hostess. Secretary,Cleaning jobs, Insurance jobs. Hasnâ€t worked in 10 years States that she could not keep a job due to alcoholism. She is not currently working but is seeking employment. History of legal issues include Civil assault charge from mother and client went to jail for 6 months. Marine boyfriend called cops on her after she threw a wine glass at him. Neighbor called cops on client and her boyfriend bc they heard them fighting. Previous boyfriend Joe was choking her and she bit him and she was in jail for 48 hours. No current legal issues rported. She reports experiencing trauma due to her fathers suicide and has na history of trauma in abusive relationships. Client was engaged to a police officer that was emotionally abusive to her. Client was 23 and the fiancée was 32 years old. Clientâ€s boyfriend Jerry died due to relapsing to heroin. The heroin he took was laced with fentanyl. Client was on the phone with boyfriend when he died, she thought he fell asleep She reports feeling safe in her current living situation with no violence occurring. She is a Christian and attends Chapel Hill church. She hasma car and hasno issues accessing healthcare.
Medical History: Anemia, Avascular necrosis, Pain from hx of crushed vertebrae, mid back, Hip pain due ro bilateral hip replacement.
 

Current Medications: 

Abilify 15mg PO daily for mood stabilization
Suboxone 8-2mg Sublingual film ½ strip TID SL for opioid dependence
Wellbutrin 150mg PO once daily for depression
Vyvance 30mg PO Daily for ADHD
Trintellix 10mg PO daily at bedtime for MDD

Allergies: Ondansetron/hives and Penicillins/rash
Surgical History: Client had double hip replacement surgery 2019

Reproductive Hx: Started menses at age 17. Never been pregnant. No issues reported with reproductive history aside from late onset menses due to athletisism. 
ROS: 
General: No fever, chills, weight change.
Head: No headaches or migraines.
Eyes: No blurred or double vision. No Cataract, No Glaucoma, Spectacles  
Ears: hearing Normal; No Discharge
Nose: Has no rhinorrhea or Discharge,orHole in septum 
Throat: No redness, soreness, exudates
Breast: No noted lumps, no tenderness, no swelling, no nipple discharge
Chest: No cough or no shortness of breath.no difficulty breathing No pain 
Heart: No high blood pressure, no irregular heartbeat. No previous heart attack, no previous bypass surgery
Gastrointestinal: No abdominal pain, no nausea, no vomiting, no diarrhea, or no constipation.
GU: no dysuria, no urinary frequency, no urinary hesitancy, no urinary tract infections, 
No kidney stones, or other urinary tract problems.
Gyn: No dysmenorrhea, no vaginal discharge, no pelvic pain, No Dyspareunia
Musculoskeletal: Has back pain, No neck pain     has joint pain, No muscle problems.
Skin: No rashes, No freckles, No Moles or other skin complaints. 
Tattoos:   Has 1 tattoo on left wrist
Body Piercings: Has 2 ear piercings
Psychiatric: Has anxiety, Has Panic Attacks. Has depression. Has Sleeping Issue
  NO PTSD.Has ADHD. NO OCD, No bipolar, No schizophrenia.
 
Physical exam: if applicable
Diagnostic results: 
Bipolar I disorder is a clinical syndromal diagnosis based on history and mental status exam, without a diagnostic laboratory test (Lee & Swartz, 2017).
Tests to assess etiologic factors include CBC, BMP, LFTs, TSH, B12, folate, vitamin D, RPR, blood alcohol level, urinalysis, and urine toxicology (Lee & Swartz, 2017).
Assessment
Mental Status Examination: This patient is a 39-year-old Caucasian female who looks younger than her stated age. She is cooperative with interviewer. She is clean and dressed appropriately for the situation and season. She is easily distracted and constantly fidgets. She is given to episodes of loose association and rambling during the interview. She displays difficulty in consentrating and appears to be struggling to focus on interview content. Her speech is pressured, of normal volume. Her thought process is logical, goal oriented. Mood is elevated and she laughs inappropriately at times. There is no evidence of delusional thought processes and shendenies any A/V hallucinations. She denies any suicidal or homicidal thoughts. She is alert and oriented in all spheres. Recent and remote memory is intact. 
Differential Diagnoses: 

Bippolar I Disorder, most recent episode hypomanic – The patient meets the DSM-V criteria for bipolar I as evidenced by having at least one previous manic episode; no evidence of schizophrenia spectrum disorder; symptoms impair social and occupational functioning; symptoms are not due to substance use, medical condition, or medication (American Psychiatric Association, 2013). The patients mother is diagnosed with BP disorder. According to Lee & Swartz (2017), there is a strong genetic basis for bipolar disorder.
Bipolar II disorder- It is important to differentiate to complete a thorough and accurate evaluation of symptoms due to the frequent misdiagnosis of bipolar spectrum disorders versus unipolar depression (Bobo, 2017). Assessing hypomanic, manic, and depressive episodes for symptom timelines andnfrequencies can help to make a correct diagnosis (Bobo, 2017). The patient meets much of the criteria for BPII (American Psychiatric Association, 2013). However, she has had an episode of mania. Thus, BPII is excluded. 
Cyclothymic Disorder- According to the DSM-V, criteria for cyclothymia include hypomania and depressive episodes that do not meet the full criteria fornhypomania or MDD; the episodes above has been present at least half the time in a two yer period with no more than two months of remission; no history of diagnosis for manic, hypomania, or depressive episodes; no psychosis, delusional or schizophrenia disorders; symptoms cannot be accounted for by substance use or a medical condition; symptoms cause distress or significant impairment in social or occupational functioning (American Psychiatric Association, 2013). “Cyclothymic disorder involves a prolonged period of unstable mood with hypomanic episodes but, unlike bipolar II disorder, the periods of low mood do not reach the threshold for a formal depressive episode”(Luty, 2020). For example, the patient may not have any suicidality or objective symptoms such as psychomotor agitation or retardation (Luty, 2020). The patient meets much but not all these criteria. The patient has been treated for MDD and the symptoms are not reported to be present for at least two years. Thus this diagnosis is excluded.

Reflections:
The patient in this case has several psychiatric comorbidities that can mask a diagnosis of bipolar disorder. According to Bobo (2017), 50%-70% of patients diagnoses with bipolar disorder have psychiatric comorbidities that include anxiety disorder and alcohol/substance use disorder. This patient has both. According to Lee & Swartz (2017), there is a strong genetic basis for bipolar disorder. Her fatherâ€s diagnosis is unknown, however, he committed suicide and her mother is diagnosed with bipolar disorder. Many patients with bipolar disorders are initially diagnosed as having unipolar major depression. Such is the case with this patient. A misdiagnosis of major depressive disorder is problematic because “antidepressants used in the absence of mood stabilizers or selected antipsychotic drugs may not be effective and can cause a switch to mania or destabilization of their illness” (Bobo, 2017). The patient is currently on a mood stabilizer and antidepressant for other psychiatric diagnoses. Even though she is taking the recommended medication, bipolar I should be added to her diagnosis. 
Legal/Ethical issues
Patients suffering from bipolar disorder are at a higher risk for suicide or attempting suicide(Bobo, 2017). Foe this reason, clinicians should identify bipolar disorder versus other psychiatric disorders in order to complete appropriate follow-up treatment. The treatment approach to bipolar disorder is different from other psychiatric illnesses as it typically has two approaches, the acute phase and the management nphase (Bobo, 2017). Each phase focuses on stabilization and maintenance of mood. However, the risk of suicidal behaviors are increased at different intervals of treatment (Bobo, 2017). For legal and ethical reasins, it is important to identify bipolar phases in order to keep the patient safe. 
 
 
 
 
 
 
 
References
American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author
Bobo, W. V. (2017). The Diagnosis and Management of Bipolar I and II Disorders: Clinical Practice Update. Mayo Clinic Proceedings, 92(10), 1532–1551. https://doi-org.ezp.waldenulibrary.org/10.1016/j.mayocp.2017.06.022
Lee, J., & Swartz, K. L. (2017). Bipolar I disorder. In Johns Hopkins Psychiatry Guide. Retrieved January 26, 2021, from https://www.hopkinsguides.com/hopkins/view/Johns_Hopkins_Psychiatry_Guide/787045/all/Bipolar_I_Disorder
Luty, J. (2020). Bordering on the bipolar: A review of criteria for ICD-11 and DSM-5 persistent mood disorders. BJPsych Advances, 26(1), 50-57. doi:10.1192/bja.2019.54
 
 
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