_NRNP _PRAC_6635_Comprehensive Psychiatric Evaluation Exemplar Sample solution

_NRNP _PRAC_6635_Comprehensive Psychiatric Evaluation Exemplar Sample solution

Complete and submit your Comprehensive Psychiatric Evaluation, including your differential diagnosis and critical-thinking process to formulate primary diagnosis. Incorporate the following into your responses in the template: Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What is 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 with supporting evidence, listed in order from highest priority to lowest priority. Compare the DSM-5-TR diagnostic criteria for each differential diagnosis and explain what DSM-5-TR criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case. Reflection notes: What would you do differently with this client if you could conduct the session over? Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).

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INSTRUCTIONS ON HOW TO USE EXEMPLAR AND TEMPLATE—READ CAREFULLY

If you are struggling with the format or remembering what to include, follow the Comprehensive Psychiatric Evaluation Template AND the Rubric as your guide. It is also helpful to review the rubric in detail in order not to lose points unnecessarily because you missed something required. Below highlights by category are taken directly from the grading rubric for the assignment in Weeks 4–10. After reviewing the full details of the rubric, you can use it as a guide.

In the Subjective section, provide:

  • Chief complaint
  • History of present illness (HPI)
  • Past psychiatric history
  • Medication trials and current medications
  • Psychotherapy or previous psychiatric diagnosis
  • Pertinent substance use, family psychiatric/substance use, social, and medical history
  • Allergies
  • ROS
  • Read rating descriptions to see the grading standards!  

In the Objective section, provide:

  • Physical exam documentation of systems pertinent to the chief complaint, HPI, and history
  • Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses.
  • Read rating descriptions to see the grading standards! 

In the Assessment section, provide:

  • Results of the mental status examination, presented in paragraph form.
  • At least three differentials with supporting evidence. List them from top priority to least priority. Compare the DSM-5-TR diagnostic criteria for each differential diagnosis and explain what DSM-5-TR criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
  • Read rating descriptions to see the grading standards!

Reflect on this case. Include: Discuss what you learned and what you might do differently. Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), social determinates of health, health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).

(The comprehensive evaluation is typically the initial new patient evaluation. You will practice writing this type of note in this course. You will be ruling out other mental illnesses so often you will write up what symptoms are present and what symptoms are not present from illnesses to demonstrate you have indeed assessed for all illnesses which could be impacting your patient. For example, anxiety symptoms, depressive symptoms, bipolar symptoms, psychosis symptoms, substance use, etc.)

EXEMPLAR BEGINS HERE

CC (chief complaint): A brief statement identifying why the patient is here. This statement is verbatim of the patient’s own words about why presenting for assessment. For a patient with dementia or other cognitive deficits, this statement can be obtained from a family member.

HPI: Begin this section with patient’s initials, age, race, gender, purpose of evaluation, current medication and referral reason. For example:

N.M. is a 34-year-old Asian male presents for psychiatric evaluation for anxiety. He is currently prescribed sertraline which he finds ineffective. His PCP referred him for evaluation and treatment.

Or

P.H., a 16-year-old Hispanic female, presents for psychiatric evaluation for concentration difficulty. She is not currently prescribed psychotropic medications. She is referred by her therapist for medication evaluation and treatment.

Then, this section continues with the symptom analysis for your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis.

Paint a picture of what is wrong with the patient. First what is bringing the patient to your evaluation.  Then, include a PSYCHIATRIC REVIEW OF SYMPTOMS.  The symptoms onset, duration, frequency, severity, and impact. Your description here will guide your differential diagnoses. You are seeking symptoms that may align with many DSM-5-TR diagnoses, narrowing to what aligns with diagnostic criteria for mental health and substance use disorders.

Past Psychiatric History: This section documents the patient’s past treatments. Use the mnemonic Go Cha MP. 

General Statement: Typically, this is a statement of the patients first treatment experience. For example: The patient entered treatment at the age of 10 with counseling for depression during her parents’ divorce. OR The patient entered treatment for detox at age 26 after abusing alcohol since age 13.

Caregivers are listed if applicable.

Hospitalizations: How many hospitalizations? When and where was last hospitalization? How many detox? How many residential treatments? When and where was last detox/residential treatment? Any history of suicidal or homicidal behaviors? Any history of self-harm behaviors?

Medication trials: What are the previous psychotropic medications the patient has tried and what was their reaction? Effective, Not Effective, Adverse Reaction? Some examples: Haloperidol (dystonic reaction), risperidone (hyperprolactinemia), olanzapine (effective, insurance wouldn’t pay for it)

Psychotherapy or Previous Psychiatric Diagnosis: This section can be completed one of two ways depending on what you want to capture to support the evaluation. First, does the patient know what type? Did they find psychotherapy helpful or not? Why? Second, what are the previous diagnosis for the client noted from previous treatments and other providers. Thirdly, you could document both.

Substance Use History: This section contains any history or current use of caffeine, nicotine, illicit substance (including marijuana), and alcohol. Include the daily amount of use and last known use. Include type of use such as inhales, snorts, IV, etc. Include any histories of withdrawal complications from tremors, Delirium Tremens, or seizures.

Family Psychiatric/Substance Use History: This section contains any family history of psychiatric illness, substance use illnesses, and family suicides. You may choose to use a genogram to depict this information. Be sure to include a reader’s key to your genogram or write up in narrative form.

Social History: This section may be lengthy if completing an evaluation for psychotherapy or shorter if completing an evaluation for psychopharmacology.  However, at a minimum, please include:

Where patient was born, who raised the patient

Number of brothers/sisters (what order is the patient within siblings)

Who the patient currently lives with in a home? Are they single, married, divorced, widowed? How many children?

Educational Level

Hobbies:

Work History: currently working/profession, disabled, unemployed, retired?

Legal history: past hx, any current issues?

Trauma history: Any childhood or adult history of trauma?

Violence Hx: Concern or issues about safety (personal, home, community, sexual (current & historical)

Medical History: This section contains any illnesses, surgeries, include any hx of seizures, head injuries.

 

Current Medications: Include dosage, frequency, length of time used, and reason for use. Also include OTC or homeopathic products.

Allergies: Include medication, food, and environmental allergies separately. Provide a description of what the allergy is (e.g., angioedema, anaphylaxis). This will help determine a true reaction vs. intolerance.

Reproductive Hx: Menstrual history (date of LMP), Pregnant (yes or no), Nursing/lactating (yes or no), contraceptive use (method used), types of intercourse:  oral, anal, vaginal, other, any sexual concerns

ROS: Cover all body systems that may help you include or rule out a differential diagnosis.  Please note: THIS IS DIFFERENT from a physical examination!

You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.

Example of Complete ROS:

GENERAL: No weight loss, fever, chills, weakness, or fatigue.

HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.

SKIN: No rash or itching.

CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.

RESPIRATORY: No shortness of breath, cough, or sputum.

GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.

GENITOURINARY: Burning on urination, urgency, hesitancy, odor, odd color

NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness.

HEMATOLOGIC: No anemia, bleeding, or bruising.

LYMPHATICS: No enlarged nodes. No history of splenectomy.

ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.

Physical exam (If applicable and if you have opportunity to perform—document if exam is completed by PCP): From head to toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head-to-toe format i.e., General: Head: EENT: etc.

Diagnostic results: Include any labs, X-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines).

Assessment

Mental Status Examination: For the purposes of your courses, this section must be presented in paragraph form and not use of a checklist! This section you will describe the patient’s appearance, attitude, behavior, mood and affect, speech, thought processes, thought content, perceptions (hallucinations, pseudohallucinations, illusions, etc.)., cognition, insight, judgment, and SI/HI. See an example below. You will modify to include the specifics for your patient on the above elements—DO NOT just copy the example. You may use a preceptor’s way of organizing the information if the MSE is in paragraph form.

He is an 8-year-old African American male who looks his stated age. He is cooperative with examiner. He is neatly groomed and clean, dressed appropriately. There is no evidence of any abnormal motor activity. His speech is clear, coherent, normal in volume and tone. His thought process is goal directed and logical. There is no evidence of looseness of association or flight of ideas. His mood is euthymic, and his affect appropriate to his mood. He was smiling at times in an appropriate manner. He denies any auditory or visual hallucinations. There is no evidence of any delusional thinking.   He denies any current suicidal or homicidal ideation. Cognitively, he is alert and oriented. His recent and remote memory is intact. His concentration is good. His insight is good.

Differential Diagnoses: You must have at least three differentials with supporting evidence. Explain what rules each differential in or out and justify your primary diagnostic impression selection. You will use supporting evidence from the literature to support your rationale. Include pertinent positives and pertinent negatives for the specific patient case.

 

Also included in this section is the reflection. Reflect on this case and discuss whether or not you agree with your preceptor’s assessment and diagnostic impression of the patient and why or why not. What did you learn from this case? What would you do differently?

Also include in your reflection a discussion related to legal/ethical considerations (demonstrating critical thinking beyond confidentiality and consent for treatment!), social determinates of health, health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).

References (move to begin on next page)

You are required to include at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines which relate to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting.

 

 

         TEMPLATE

 

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

 

 

 

 

 

 

 

 

 

 

 

 

Subjective:

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:

Objective:

Physical exam: if applicable

Diagnostic results:

Assessment:

Mental Status Examination:

Differential Diagnoses:

Reflections:

References

 

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_NRNP _PRAC_6635_Comprehensive Psychiatric Evaluation Exemplar Sample solution

Assessing and Diagnosing Patients With Schizophrenia, Other Psychotic Disorders, and Medication-Induced Movement Disorders

When treating patients with psychotic illnesses, practitioners must be aware of the symptomatic patterns that could impair a patient ‘s ability to function in daily life. Psychosis may present in a variety of ways depending on the individual patient. Symptoms such as delusions or hallucinations may be more pronounced in some people, while symptoms like these may be barely perceptible in others. A 25-year-old woman has just had a psychotic episode, and the purpose of this study is to assess her and determine possible diagnoses.

Subjective:

CC (chief complaint): difficulty at work and pain in the neck

HPI: Ms. Branning is a 25-year-old woman who comes to the facility with a coworker who mentions that Ms. Branning’s output at work has been lower than usual. The patient reports that she is experiencing problems at work and feels that the supervisor is in love with her, which is leading her to fear that her employer is planning to fire her. Additionally, the patient complains of experiencing pain in her neck, which radiates to her back and continues to worsen. She is under the impression that the pain is the result of cancer, which is brought by the agony, heartbreak, and suffering that she undergoes at the hands of her coworkers. She asserts that she has not been subjected to sexual assault in the workplace.

Past Psychiatric History:

  • General Statement: refused to share past psychiatric diagnoses and treatments
  • Caregivers (if applicable): N/A
  • Hospitalizations: None
  • Medication trials: Unknown
  • Psychotherapy or Previous Psychiatric Diagnosis:Unknown

Substance Current Use and History:Unknown

Family Psychiatric/Substance Use History: Denies mental health issues in her family

Psychosocial History: Ms. Branning lives alone in Santa Monica, California. She is her family’s only child, having been brought up by her mother and father. She states that she is not married, but she is open about the fact that she has a boyfriend. She has a bachelor’s degree in business and is currently employed in the office supplies sales sector. She blames the escalating level of neck pain she has been experiencing on the lack of sales she has made in the past three weeks.

Medical History: Hypothyroidism

  • Current Medications: levothyroxine
  • Allergies: medical tape
  • Reproductive Hx:Regular menstrual cycle. Never been pregnant.

ROS: In this particular case, a Review of Systems is not included. From the details provided in the case, one may derive the ROS as shown below. ROS is an essential component of the psychiatric evaluation since it provides the practitioner with information that may be helpful when making recommendations for diagnostic testing (Okland al., 2017).

  • GENERAL: Denies fever, chills, fatigue, or weight changes
  • HEENT: Denies hearing problems, vision changes, or headaches.
  • SKIN: Denies rash, itching, lesons, or discoloration
  • CARDIOVASCULAR: Denies edema, chest tightness, palpitations, and chest pain.
  • RESPIRATORY: Denies cough, wheezing, or breathing problems
  • GASTROINTESTINAL: Denies constipation, vomiting, nausea, diarrhea, and abdominal pain.
  • GENITOURINARY: Denies frequent urination, hesitancy, or pain on urination
  • NEUROLOGICAL: Denies dizziness, numbness or tingling, vertigo, or headaches.
  • MUSCULOSKELETAL: Reports neck pain that radiates to her back.
  • HEMATOLOGIC: Denies bleeding or history of anemia
  • LYMPHATICS: Reports a lump located in her neck. Denies history of splenectomy
  • ENDOCRINOLOGIC: Denies excessive urination, excess thirst, or heat or cold intolerance.

Objective:Vital Signs: T- 98.4 P- 80 R 18 128/78 Ht 5’0 Wt 120lbs

Physical exam: In this case, a physical examination is not performed, which could have assisted in determining the likelihood of physiological factors contributing to the client’s health condition.

Diagnostic results: In this specific case, the Peters et al. Delusions Inventory, needs to be ordered so as to help in the identification and evaluation of delusional thoughts. Using this test, one may see the many facets of delusional thinking, like the severity of emotional distress (Matheson al., 2020). On the other hand, in order to get a more precise diagnosis of neck pain, the practitioner may think about employing x-rays, MRI, and CT scans.

Assessment:

Mental Status Examination: The patient appears well-dressed, well-groomed and well-nourished.  She was difficult with the interviewer at times, and she refused to address questions that were asked. The client exhibits some mild motor agitation as she repeatedly points to her neck, which is the location of the pain that she is reporting. She has a                                                                         watchful eye contact, which demonstrates her heightened level of vigilance in light of the fact that she is suspicious of the interviewer and is always looking around the place. When the interviewer asks her about her health concerns, her normally subdued tone of voice suddenly becomes more assertive. Her mood is irritable with a flat affect. She exhibits illogical thought process, thought obstruction, and and a lack of thought pattern. Delusions are noted in her thought content. Her cognition and memory are intact. She demonstrates impaired judgment and lack of insight into her health condition. Patient has no auditory or visual hallucinations, suicidal or homicidal ideations.

Differential Diagnoses:

  1. Delusional Disorder- Delusional disorder is a kind of mental disease that is distinguished from other forms of psychosis by the presence of delusions over a period of at least one month but not other psychotic indications (González-Rodríguez & Seeman, 2022). According to the DSM-5-TR, the specific criteria for delusional disorder include the existence of one or more delusions that have lasted for at least one month, nonfulfilment of schizophrenia’s diagnostic criteria, the functionality of the patient has not significantly deteriorated, and that there is not other mental condition that more adequately explains the problem. This is most likely the correct diagnosis for the patient in question taking into consideration her delusional symptoms.
  2. Schizophrenia- Schizophrenia is a severe mental condition in which a person has aberrant perceptions of the world around them. Schizophrenia may be the cause of a variety of symptoms, including delusions, hallucinations, and profoundly disorganized thought and behavior, all of which interfere with everyday functioning and have the potential to be incapacitating (Stępnicki et al., 2018). The DSM-5 specifies that in order to diagnose schizophrenia, a patient must have at least two of the following five primary symptoms: hallucinations, delusions, disordered or incoherent speech, fragmented or odd movements, and adverse symptoms. It is probable that this patient is suffering from Schizophrenia as a result of the intense delusions that she has been experiencing.
  3. Bipolar Disorder with Psychotic Features- A condition characterized by recurrent periods of extreme shifts in mood, which may range from depressed lows to manic highs. Delusions and hallucinations may occur at any time throughout a manic or hypomanic episode in someone who has bipolar illness with psychotic features (APA, 2013). It is improbable that this diagnosis is correct for the patient given that she does not exhibit any manic or depressed symptoms.

Reflections:

It is important to constantly note the challenges that medical personnel may confront while conducting interviews with patients who are unwilling to cooperate. This is due to the fact that getting information from a delusional person who is reticent might be difficult to accomplish. When dealing with individuals who suffer from delusions, practitioners have a duty to be cognizant of the ethical considerations involved, which include having patients included in the decision-making process and getting their consent (Bartels & Ryan, 2018). Individuals who suffer from delusions may have poor judgment, but this does not absolve a professional of his or her obligation to get their informed consent. It is crucial to build a connection with clients in order to obtain their informed consent because doing so will make them have faith in the professional’s capacity to provide appropriate medical treatment.

 

 

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub.

Bartels, J., & Ryan, C. J. (2018). How should physicians use their authority to name a stigmatizing diagnosis and respond to a patient’s experience?. AMA Journal of Ethics, 20(12), 1119-1125. https://doi.org/10.1001/amajethics.2018.1119

González-Rodríguez, A., & Seeman, M. V. (2022). Differences between delusional disorder and schizophrenia: A mini narrative review. World Journal of Psychiatry, 12(5), 683-692. https://doi.org/10.5498/wjp.v12.i5.683

Matheson, G. J., Plavén-Sigray, P., Louzolo, A., Borg, J., Farde, L., Petrovic, P., & Cervenka, S. (2020). Dopamine D1 receptor availability is not associated with delusional ideation measures of psychosis proneness. Schizophrenia Research, 222, 175-184. https://doi.org/10.1016/j.schres.2020.06.001

Okland, T. S., Gonzalez, J. R., Ferber, A. T., & Mann, S. E. (2017). Association between patient review of systems score and Somatization. JAMA Otolaryngology–Head & Neck Surgery, 143(9), 870. https://doi.org/10.1001/jamaoto.2017.0671

 Stępnicki, P., Kondej, M., & Kaczor, A. A. (2018). Current concepts and treatments of schizophrenia. Molecules, 23(8), 2087. https://doi.org/10.3390/molecules23082087

 

 

 

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