PRAC 6635 WEEK 7 Comprehensive Psychiatric Evaluation and Patient, Video Case Presentation
University:
Walden University
PRAC 6635 WEEK 7 Comprehensive Psychiatric Evaluation and Patient, Video Case Presentation
Paper Instructions
To Prepare
Review this week’s Learning Resources and consider the insights they provide about assessment and diagnosis. Also review the Kaltura Media resource in the Classroom Support Center (accessed via the Help button).
Select a patient that you examined during the last 2 weeks who presented with a disorder other than the one present in your selected case for Week 5.
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.
Develop a video case presentation, based on your evaluation 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
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 7 Assignment 2, Part 2 you will the Comprehensive Psychiatric Evaluation including two (2) files for the 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)
Informant (Mother) – My daughter does not respond to her name and she avoids eye contact
HPI
S.V. is a 4-year-old girl accompanied to the psychiatric clinic by her mother after a referral from the pediatrician. The girl’s mother reports that she fails to respond to her name, reduced eye contact, and has a regression of language skills. The mother also reports she cannot start a conversation, keep one going, or only start one to make requests or label items. The child speaks in an abnormal tone and rhythm, often repeats words and phrases, and does not understand simple questions. The mother also reports she has repetitive movements, such as hand flapping, and performs activities that may cause harm and is disturbed when routine is affected.
Past Psychiatric History
- General Statement: The patient has no significant psychiatric history.
- Caregivers (if applicable): The patient’s mother.
- Hospitalizations: No history of psychiatric admission.
- Medication trials: None
- Psychotherapy or Previous Psychiatric Diagnosis: No history of psychotherapy or psychiatric diagnosis.
Substance Current Use and History
No history of exposure to alcohol, tobacco smoke, or other drug substances.
Family Psychiatric/Substance Use History
The mother had a history of postpartum depression when the child was four weeks old. The maternal uncle has a history of alcohol abuse and Bipolar disorder.
Psychosocial History
The boy is the firstborn and has one younger brother who is one year old.
Medical History
The patient has no history of chronic illnesses or recurrent infections. No history of surgery. Immunization is up to date.
- Current Medications: None
- Allergies: None
Reproductive Hx
Not applicable
ROS
- GENERAL: Denies fever, chills, weight gain/loss, or body weakness.
- HEENT: Denies head injury, visual changes, tearing, eye pain, ear discharge/pain, tinnitus, sneezing, nasal discharge, rhinorrhea, or sore throat.
- SKIN: Denies rashes, bruises, discoloration, or lesions.
- CARDIOVASCULAR: No edema, palpitations, dyspnea, or chest pain.
- RESPIRATORY: No cough, wheezing, sputum, dyspnea, or chest pain
- GASTROINTESTINAL: No nausea, vomiting, loss of appetite, abdominal pain, diarrhea, bloating, or constipation.
- GENITOURINARY: No pain during urination, urinary frequency, urgency, or blood in urine.
- NEUROLOGICAL: No headaches, syncope, muscle weakness, or numbness.
- MUSCULOSKELETAL: No muscle pain, fractures, joint stiffness, or pain.
- HEMATOLOGIC: No history of anemia, bleeding, or bruises.
- LYMPHATICS: No enlarged lymph nodes.
- ENDOCRINOLOGIC: No heat/cold intolerance, excessive sweating, polyuria, acute hunger, or thirst.
Physical exam if applicable
Diagnostic results
No diagnostic tests were ordered.
Assessment
Mental Status Examination
The girl is neat, appropriately dressed, and sits on the mother’s lap. The child is alert and hyper-vigilant. She expresses mutism and has a blunted affect with repetitive abnormal movements. She has minimal interactions with people around her.
Differential Diagnoses
Autism Spectrum Disorder (ASD)
ASD is a neurological developmental disorder characterized by developmental disabilities, which contribute to marked difficulties in social interactions, behavior, and communication. Children with ASD present with persistent deficits in social communication and social interaction across multiple contexts (Hyman et al., 2020). They have restricted, repetitive patterns of behavior, interests, or activities.
The symptoms usually result in clinically significant impairment in social, occupational, or other important areas of current functioning (Hodges et al., 2020). ASD was the primary diagnosis since the child exhibited deficits in social-emotional reciprocity and nonverbal communicative behaviors used for social interaction. The girl also insisted on sameness and had inflexible adherence to routines. Communication and social interaction challenges were evident in the patient.
Social Communication Disorder (SCD)
SCD is characterized by impairment in using verbal and nonverbal communication for social aims (Flax et al., 2019). The DSM-5 diagnostic criteria for SCD include Persistent difficulties in the social use of verbal and nonverbal communication; Deficits in using communication for social purposes; Impairment in the ability to change communication to match the context or the needs of the listener; Difficulties following rules for conversation and storytelling; Difficulties understanding what is not explicitly stated and non-literal or ambiguous meaning of language (Flax et al., 2019). The child has difficulties in starting and maintaining conversations, making SCD a differential diagnosis.
Intellectual/Learning Disability
This is characterized by difficulties in the acquisition and use of language across modalities. Children with this disorder have persistent difficulties in reading, writing, arithmetic, or mathematical reasoning skills during formal years of schooling (Blanchet & Assaiante, 2022). They have learning difficulties, and their academic skills are below average. The child has a regression of language skills and fails to understand simple questions, which aligns with the diagnosis of a Learning disability (Blanchet & Assaiante, 2022).
Reflections
In a similar patient evaluation, I would assess the patient for ASD comorbidities. This is because most children with ASD have mood or attention disorders. Al-Beltagi (2021) explains that depression and suicide occur more often in patients with ASD, making screening vital in affected patients. Sleeping difficulties are also common and often worsen behavior issues and limit the effectiveness of behavior therapies. More than half of children with ASD have one or more chronic sleep problems. Thus, I would assess the child for sleeping difficulties. The prognosis and outcomes in patients with ASD are influenced by social determinants of health (SDOH). Magaña et al. (2023) explain that SDOHs like food insecurity, low socioeconomic status, and housing insecurity are more prevalent among families of children with ASD.
Health promotion for a patient with ASD should include educating the parents or caregivers on the available community resources for children and parents/caregivers with ASD. Furthermore, parents and caregivers should be educated on how to take care of themselves since caring for a child with ASD can be physically and emotionally exhausting. Patient education should also include educating the parents on the risk of getting another child with autism (Hodges et al., 2020). They can be informed about genetic counseling and related tests like Fragile X testing.
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
- Al-Beltagi, M. (2021). Autism medical comorbidities. World journal of clinical pediatrics, 10(3), 15–28. https //doi.org/10.5409/wjcp.v10.i3.15
- Blanchet, M., & Assaiante, C. (2022). Specific Learning Disorder in Children and Adolescents, a Scoping Review on Motor Impairments and Their Potential Impacts. Children (Basel, Switzerland), 9(6), 892. https //doi.org/10.3390/children9060892
- Flax, J., Gwin, C., Wilson, S., Fradkin, Y., Buyske, S., & Brzustowicz, L. (2019). Social (pragmatic) communication disorder Another name for the broad autism phenotype? Autism, 23(8), 1982-1992. https //doi.org/10.1177/1362361318822503
- Hodges, H., Fealko, C., & Soares, N. (2020). Autism spectrum disorder definition, epidemiology, causes, and clinical evaluation. Translational pediatrics, 9(Suppl 1), S55–S65. https //doi.org/10.21037/tp.2019.09.09
- Hyman, S. L., Levy, S. E., Myers, S. M., Kuo, D. Z., Apkon, S., Davidson, L. F., … & Bridgemohan, C. (2020). Identification, evaluation, and management of children with autism spectrum disorder. Pediatrics, 145(1). https //doi.org/10.1542/peds.2019-3447
- Magaña, S., Eliasziw, M., Bowling, A., & Must, A. (2023). Racial and ethnic disparities in obesity and contributions of social determinants of health among boys with autism spectrum disorder. Frontiers in Pediatrics, 11. https //doi.org/10.3389/fped.2023.1198073
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