PRAC 6635 Comprehensive Psychiatric Evaluation and Patient Case Presentation
University:
Walden University
PRAC 6635 Comprehensive Psychiatric Evaluation and Patient Case Presentation
Paper Instructions
To Prepare
Review this week’s Learning Resources and consider the insights they provide. Also review the Kaltura Media resource in the Classroom Support Center area (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 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.
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.
By Day 7
Submit your Video Case Presentation.
Note: In Week 9 Assignment 2, Part 2 you will submit two (2) files for the Comprehensive Psychiatric 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.
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Sample Answer
CC (chief complaint)
“They tell me that I see and hear imaginary things.”
HPI
D.L. is a 32-year-old female who presented to the psychiatric clinic accompanied by her sister with reports that people have been telling her that she sees and hears imaginary things. This started nine months ago when she started hearing strange voices at night and would often wake up thinking that thieves were attacking them. She has woken up her family members several times due to the strange voices at night, and they are now concerned that this is getting out of hand. In addition, she reports that she, at times, sees things that others cannot see. This has worsened in the past six months until her family forced her to see a psychiatrist.
The client’s sister further reports that the patient talks of strange things, like the mayor being in love with her. Even though she has never met the current mayor, she is convinced that the mayor loves her. She has been watching the news in the past months with expectations that the mayor will appear in the news. She also replays the mayor’s past speeches on YouTube. She often demonstrates bizarre behavior and creates new words. She can no longer do any of her normal previous activities and no longer finds enjoyment in previously enjoyable activities.
Past Psychiatric History
- General Statement: The patient had depression at 24 years.
- Caregivers (if applicable): None.
- Hospitalizations: None.
- Medication trials: Zoloft and Fluoxetine for depression.
- Psychotherapy or Previous Psychiatric Diagnosis: Major depression.
Substance Current Use and History
The patient is an occasional alcohol drinker. She does not smoke tobacco or abuse illegal substances.
Family Psychiatric/Substance Use History
The patient’s mother had an alcohol addiction disorder and abused alcohol during pregnancy. The father had depression and committed suicide. All siblings are alive and well.
Psychosocial History
The patient is single, and she has no children. She lives with her mother and younger sibling. She dropped out of college and was recently working at a fast-food joint before being fired three months ago. Her hobbies are swimming and traveling.
Medical History
No history of chronic illnesses or surgery.
- Current Medications: Sertraline 100mg at night.
- Allergies: None
Reproductive Hx
No history of gynecologic/obstetric conditions.
ROS
- GENERAL: Denies fever, malaise, or body weakness.
- HEENT: Denies head injury, visual changes, eye pain, or excessive lacrimation. Denies ear pain, discharge, hearing loss, nasal discharge, sneezing, nasal blockage, throat pain, or hoarseness.
- SKIN: Denies skin discoloration, rashes, lesions, or bruises.
- CARDIOVASCULAR: Denies chest pain, palpitations, SOB or edema.
- RESPIRATORY: Denies history of cough, SOB, wheezing, or TB.
- GASTROINTESTINAL: Denies nausea, vomiting, abdominal cramping, diarrhea or constipation.
- GENITOURINARY: Denies urinary urgency, frequency, pain during urination, or blood in urine. Denies urethral discharge or genital ulcers.
- NEUROLOGICAL: Denies excessive fatigue, dizziness, tingling sensations, and headaches.
- MUSCULOSKELETAL: Denies muscle pain, back pain, joint pain and stiffness.
- HEMATOLOGIC: Denies anemia, bruising, or bleeding.
- LYMPHATICS: Denies enlarged lymph nodes.
- ENDOCRINOLOGIC: Denies excessive sweating, acute thirst, hunger, or increased urination.
Physical exam if applicable
Diagnostic results
- Drug screening test- negative.
Assessment
Mental Status Examination
The patient is alert but disoriented to person, place, and time. She is agitated and cannot maintain eye contact. She is inappropriately dressed and unkempt. She is irritable and has a blunted affect. She speaks in a fast and high tone with very long and extremely irrelevant answers. Visual and auditory hallucinations and erotomania delusions were present. She has an incoherent thought process, looseness of association, perseveration, word salad, and neologisms. There are gaps in her memory. She lacks insight.
Differential Diagnoses
Schizophrenia
Symptoms of schizophrenia include positive, negative, cognitive, and disorganized symptoms. Positive symptoms include delusions and hallucinations. Negative symptoms include loss of interest, blunt affect, poverty of speech, and lack of interest in social relationships (McCutcheon et al., 2020). Cognitive symptoms include memory, attention, and abstract thought deficits. Disorganized symptoms include thought disorders and bizarre behaviors (McCutcheon et al., 2020). The patient has visual and auditory hallucinations, erotomanic delusions, bizarre behavior, incoherent thought process, looseness of association, disorganized speech, and loss of interest in activities, making schizophrenia a primary diagnosis.
Schizoaffective Disorder
This condition is characterized by features of schizophrenia and mood disorder. However, the patient does not usually meet the diagnostic criteria for any of the two conditions. Patients with schizoaffective disorder have a history of depression or mania at least once in the course of illness (Miller & Black, 2019). The diagnostic criteria require a patient to have mood symptoms for more than 50% of the duration of illness coexisting with symptoms of schizophrenia. This is a differential diagnosis based on the presence of psychotic symptoms and the patient’s history of depression.
Brief Psychotic Disorder
It manifests with a sudden onset of psychotic symptoms, including hallucinations, delusions, bizarre behavior, and disorganized speech. Brief psychotic disorder is also characterized by disorientation, impaired attention, inappropriate dressing, and impaired memory (Vyas et al., 2023). The symptoms occur for a short duration of less than one month, and the patient returns to normal functioning. Brief psychotic disorder is a differential diagnosis as per positive findings of hallucinations, delusions, disorganized speech, bizarre behavior, inappropriate grooming, and disorientation. However, it is unlikely to be a primary diagnosis based on the duration of the patient’s symptoms, which have occurred for nine months (Provenzani et al., 2021).
Reflections
In a different situation, I would use screening tools designed for clinical assessment of schizophrenia. For example, I would use the Positive and Negative Syndrome Scale (PANSS), which is the gold standard scale in clinical and psychopharmacological studies of schizophrenia (Yildiz et al., 2021). Health promotion for this patient should include vocational rehabilitation training to help the patient work and care for herself. Disease prevention should include education on the importance of a healthy diet and regular physical activity. The patient should be counseled on taking a healthy diet to promote a healthy weight. She should also be advised to engage in daily physical activities since psychotropic medications cause significant weight gain and alterations in glucose and lipid metabolism (Kaasgaard et al., 2023). Furthermore, regular physical exercises help to boost brain health and accelerate recovery in schizophrenia.
PRECEPTOR VERIFICATION
I confirm the patient used for this assignment is a patient that was seen and managed by the student at their Meditrek approved clinical site during this quarter course of learning.
Preceptor signature ________________________________________________________
Date ________________________
References
- Kaasgaard, D. M., Stryhn, L., Veldt Larsen, P., Fisker, L., Friis Elliott, A., Høgh, L., Thunberg, R., Knudsgaard Sørensen, M., Martinsen, P., Kjær Hansen, H., Munk-Jørgensen, P., & Hjorth, P. (2023). Outpatients with psychotic disorders need physical health-promoting treatment A cross-sectional multisite study. Heliyon, 9(11), e21670. https //doi.org/10.1016/j.heliyon.2023.e21670
- McCutcheon, R. A., Marques, T. R., & Howes, O. D. (2020). Schizophrenia—an overview. JAMA psychiatry, 77(2), 201-210. doi 10.1001/jamapsychiatry.2019.3360
- Miller, J. N., & Black, D. W. (2019). Schizoaffective disorder A review. Annals of clinical psychiatry official journal of the American Academy of Clinical Psychiatrists, 31(1), 47-53.
- Provenzani, U., Salazar de Pablo, G., Arribas, M., Pillmann, F., & Fusar-Poli, P. (2021). Clinical outcomes in brief psychotic episodes a systematic review and meta-analysis. Epidemiology and psychiatric sciences, 30, e71. https //doi.org/10.1017/S2045796021000548
- Vyas, C. M., Petriceks, A. H., Paudel, S., Donovan, A. L., & Stern, T. A. (2023). Acute Psychosis Differential Diagnosis, Evaluation, and Management. The Primary Care Companion for CNS Disorders, 25(2), 46311. https //doi.org/10.4088/PCC.22f03338
- Yildiz, M., Incedere, A., Gürcan, M. B., & Osman, E. (2021). Brief Clinical Assessment Scale for Schizophrenia (BCASS) Development, Validity, and Reliability Study. Noro psikiyatri arsivi, 59(1), 14–20. https //doi.org/10.29399/npa.27592
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