PRAC 6645 Comprehensive Psychiatric Evaluation Note and Patient Case Presentation, Part 1
University:
Walden University
PRAC 6645 Comprehensive Psychiatric Evaluation Note and Patient Case Presentation, Part 1
Paper Instructions
To Prepare
Review this week’s Learning Resources and consider the insights they provide about impulse-control and conduct disorders.
Select a patient for whom you conducted psychotherapy for an impulse control or conduct disorderduring the last 6 weeks. Create a Comprehensive Psychiatric Evaluation Note on this patient using the template provided in the Learning Resources.
There is also a completed template provided as an exemplar and guide. All psychiatric evaluation notes must be signed by your Preceptor. When you submit your note, you should include the complete comprehensive evaluation note as a Word document and pdf/images of the completed assignment signed by your Preceptor. You must submit your note using Turnitin.
Please Note: Electronic signatures are not accepted. If both files are not received by the due date, Faculty will deduct points per the Walden Grading Policy.
Then, based on your evaluation of this patient, develop a video presentation of the case. Plan your presentation using the Assignment rubric and rehearse what you plan to say. Be sure to review the Kaltura Media Uploader resource in the left-hand navigation of the classroom for help creating your self-recorded Kaltura video.
- Include at least five scholarly resources to support your assessment and diagnostic reasoning.
- Ensure that you have the appropriate lighting and equipment to record the presentation.
The 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 complex case study. Be succinct in your presentation, and do not exceed 8 minutes. Include subjective and objective data; assessment from most recent mental status exam; current psychiatric diagnosis including differentials that were ruled out; current psychotherapeutic plan (include one health promotion activity and one patient education strategy you provided); and patient progress toward treatment goals.
Subjective
- What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis?
- What was the duration and severity of their symptoms?
- How are their symptoms impacting their functioning in life?
Objective
- What observations did you make during the psychiatric assessment?
Assessment
- Discuss the patient’s mental status examination results. What were your differential diagnoses?
- Provide a minimum of three possible diagnoses in order of highest to lowest priority and explain why you chose them.
- What was your primary diagnosis and why?
- Describe how your primary diagnosis aligns with DSM-5-TR diagnostic criteria and is supported by the patient’s symptoms.
Plan
Describe your treatment modality and your plan for psychotherapy. Explain the principles of psychotherapy that underline your chosen treatment plan to support your rationale for the chosen psychotherapy framework.
- What were your follow-up plan and parameters?
- What referrals would you make or recommend as a result of this psychotherapy session?
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.
Submission information – Part 1 Recording
To submit your video response entry:
- 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
Subjective
CC (chief complaint)
“Need help as soon as possible
HPI
B.C is a ten-year-old male patient who was brought to the clinic by his mother for a psychiatric assessment. The mother indicates that she thinks her son needs help as soon as possible. She reports being worried by his son’s defiant behavior. What worries her more is that her son has shown defiance symptoms more frequently as he continuously defies orders and instructions both in school and at home. The boy hates taking directions and instructions from older siblings at home and sometimes even gets angry when instructed by the mother. He also shows similar symptoms in school as he argues a lot with fellow learners and doesn’t like following teachers’ instructions.
Consequently, he finds it hard to complete home and school work as he should. The patient also throws tantrums and displays anger and aggression whenever he is corrected. Reports from school also show that he frequently gets into verbal disagreements and likes disrupting others.(include psychiatric ROS rule out)
Past Psychiatric History
- General Statement: The patient has no previous entry to treatment. Therefore, this will be his first experience
- Caregivers (if applicable): He lives with his mother, who is also the caregiver
- Hospitalizations: No history of hospitalizations
- Medication trials: No records of medication trials
- Psychotherapy or Previous Psychiatric Diagnosis: The patient has no history of psychotherapy or previous psychiatric diagnosis
Substance Current Use and History
The patient is only ten years old and has not used any substance in the past. He also denies past usage.
Family Psychiatric/Substance Use History
The patient’s father was once treated for depression, while his elder brother has a history of PTSD. There is no family substance use history.
Psychosocial History
The patient was born in Memphis and currently lives with his mother and two older siblings; the father lives in a different city but comes to his family during weekends. He has two older siblings, a brother and a sister. The patient is currently attending early school grade and likes watching soccer. There is no trauma history nor a concerning violence history.
Medical History
- Current Medications: The patient is currently not using any medications
- Allergies: No known allergies
Reproductive Hx
No notable reproductive history, as he is a child
Objective
Vital signs
- Temp – 98.0
- Pulse – 78
- Respiration – 18
- B/P – 100/68
- Height – 58 inches
- Weight – 30 kg
Diagnostic results
No labs or X-rays are needed
Assessment
Mental Status Examination
The patient has well and appropriately been dressed by the mother. He is also well-groomed. The patient is also alert and oriented in person, time, and place. His speech is clear and coherent. The boy is, however, argumentative and asks lots of questions. The patient’s concentration is low, and he keeps walking up and down in the examination room. His thought process is age-appropriate and coherent. The patient’s short-term and long-term memory are also intact. He denies suicidal thoughts or ideations. He also denies hallucinations, obsessions, or phobias.
Differential Diagnoses
a) Oppositional Defiant Disorder (ODD)
This is a conduct disorder known to start mainly during childhood or adolescence. A patient with the condition may have various symptoms, such as persistent patterns of hostility, disobedience, defiance, and negative behavior directed toward authority figures (Lin et al.,2022). The patient exhibited a persistent pattern of defiant, disobedient, and argumentative behavior in home and school settings. Therefore, these symptoms make ODD a potential diagnosis and primary diagnosis.
b) Disruptive Mood Dysregulation Disorder (DMDD)
This is another condition known to majorly affect children and adolescents. A patient with this condition may present with severe and recurrent temper outbursts, which are usually out of proportion or inconsistent with developmental levels (Laporte et al.,2021). The patient has been presenting with recurrent irritability, anger, and tantrums, which makes this condition a potential diagnosis. However, it is important to note that no reports were given of mood outbursts being out of the proportion to the situation.
c) Attention-Deficit/Hyperactivity Disorder (ADHD)
This is a neurodevelopmental disorder known to begin in childhood. However, the condition can persist into adolescence and even adulthood. A patient with this condition may present with various symptoms such as impulsivity, hyperactivity, and inattention, which end up substantially impacting their daily function, life, and development (Song et al.,2021). The patient presented with disruptive and impulsive behaviors at home and in school settings. He also finds it difficult to complete his work, which could point to inattention.
Reflections
This is another patient case that offers an opportunity to learn and acquire more relevant skills in psychiatric assessment and diagnostic reasoning. I agree with the preceptor’s assessment since the diagnoses covered for this patient are supported by evidence. I have learned various aspects of this case. One of them is the need to carry out a comprehensive patient assessment for better diagnosis. It is also important to seek the views of the patient’s family members to get a complete history and background that could be impacting the patient.
One thing I would do differently is get more information from the teachers, especially on how the patient’s performance has been impacted since the symptoms started. I would also be interested in knowing how the patient behaves in the presence of his father. It is important to consider legal or ethical aspects in this case. For example, the family members, such as the mother, should take a central role in the formulation of care as part of fulfilling patient autonomy (Hunt-Grubbe, 2020). It is also important to ensure that this patient’s health information remains private and confidential, as such, no unauthorized person should be offered access.
One of the social determinant of health that can be considered in this case is access to healthcare. The patient may need to start psychotherapy sessions, so it is important to inquire if the family has transportation means and adequate medical cover, as they could hinder the necessary healthcare access.
Case Formulation and Treatment Plan
The patient assessment, objective information and subjective information point to oppositional defiant disorder. The implication is that there is a need to formulate an appropriate plan for this patient to help treat and manage the symptoms for better outcomes. Since the patient has never been treated before for these symptoms, it is important to start weekly sessions of family therapy to help in the management of his defiant behaviors (Doepfner et al.,2020). The patient should visit the facility after four weeks to view the progress and make appropriate adjustments in case the symptoms persist. For example, there will be a need to incorporate medications to help the patient based on what is observed after the four weeks. This approach should help for all three diagnoses in the differential diagnosis part.
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
- Doepfner, M., Goertz‐Dorten, A., Hanisch, C., & Steinhausen, H. C. (2020). Treatment and management of oppositional defiant disorders and conduct disorders in children and adolescents. The Wiley International Handbook on Psychopathic Disorders and the Law, 729-777. https //doi.org/10.1002/9781119159322.ch32
- Hunt-Grubbe, H. (2020). Ethical Issues Arising from the Prescription of Antipsychotic Medication in Clinical Forensic Settings. In Ethical Issues in Clinical Forensic Psychiatry (pp. 99-114). Springer, Cham. https //doi.org/10.1007/978-3-030-37301-6_6
- Laporte, P. P., Matijasevich, A., Munhoz, T. N., Santos, I. S., Barros, A. J., Pine, D. S., … & Salum, G. A. (2021). Disruptive mood dysregulation disorder symptomatic and syndromic thresholds and diagnostic operationalization. Journal of the American Academy of Child & Adolescent Psychiatry, 60(2), 286-295. https //doi.org/10.1016/j.jaac.2019.12.008
- Lin, X., He, T., Heath, M., Chi, P., & Hinshaw, S. (2022). A systematic review of multiple family factors associated with oppositional defiant disorder. International Journal of Environmental Research and Public Health, 19(17), 10866. https //doi.org/10.3390/ijerph191710866
- Song, P., Zha, M., Yang, Q., Zhang, Y., Li, X., & Rudan, I. (2021). The prevalence of adult attention-deficit hyperactivity disorder A global systematic review and meta-analysis. Journal of Global Health, 11. https //doi.org/10.7189%2Fjogh.11.04009
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