COMPREHENSIVE PSYCHIATRIC EVALUATION AND PATIENT CASE, DOCUMENTATION
Order Instructions
Hello, below is the information of my patient for this assignment and the instructions for the assignment. This is a professional nurse practitioner program, so please use critical thinking with diagnoses and reflection. Please see the template for this assisgnment and exampler attached. Please use template for this assignment. Use APA 7 format for citation and references. Please let me know if you need more info.
Assignment instruction:
Comprehensive psychiatric evaluations are a way to reflect on your practicum experiences and connect the experiences to the learning you gain from your weekly Learning Resources. Comprehensive notes, such as the ones required in this practicum course, are often used in clinical settings to document patient care.
For this Assignment, you will document information about a patient that you examined during the last 2 weeks, using the Comprehensive Psychiatric Evaluation Template provided. You will then use this note to develop and record a case presentation for this patient.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.
Develop a 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.
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.
LEARNING RESOURCES
Required Readings
Carlat, D. J. (2017). The psychiatric interview (4th ed.). Wolters Kluwer.
Chapter 27, “Assessing Psychotic Disorders”
HSoft Corporation. (2020). Meditrek: HomeLinks to an external site.. https://edu.meditrek.com/Default.html
Note: Use this website to log into Meditrek to report your clinical hours and patient encounters.
Document: Comprehensive Psychiatric Evaluation Template Download Comprehensive Psychiatric Evaluation Template(Word document)
Document: Comprehensive Psychiatric Evaluation Exemplar Download Comprehensive Psychiatric Evaluation Exemplar(Word document)
The Patient info:
Subjective: Patient J.B. is a 33-year-old Caucasian female who presents for initial psychiatric evaluation with consent obtained. She is currently in an inpatient treatment facility for addiction. She reported that she wants to “continue out-patient treatment because she is a recovering addict”. She noted that she abuses crack cocaine and has been in the treatment facility since August 25, 2023, and is expected to be discharged on October 4th, 2023. She reported that she also abuses alcohol and she “drinks to blackout”. She stated that she tends to be restless, can’t stay still and always looking for something to do. She reported that she makes bad choices whenever she is under the influence of drugs. The client stated that she has been diagnosed with PTSD, Anxiety, Epilepsy, and Asthma. She noted that she grew up with her mother and 6 siblings (four brothers and two sisters). She stated that her father wasn’t in the picture and was also an addict. She reported that she was sexually abused by her cousin as a child and has experienced domestic violence from her last partner who she claimed kicked her in the stomach and injured her spleen. She completed high school and proceeded to cosmetology school. She has three kids from three different men with the last child being 9 months old. She was never married. she stated that she was on a pre-trial release for 2nd-degree assault 4 months ago for breaking the nose of her partner’s female friend. she noted that she has an anger management problem.
Objective:
General Appearance:
Neat & clean., Poor Hygiene. Tired. Disheveled. Inappropriate. Other:
Eye contact: Normal. Avoidant. Intense. Other
Psychomotor Activity: Normal, retarded or rigidity/repetitive movements
Orientation: Person. Place. Time. Situation.
Attention: Intact. Distracted. Confused. Inattentive. Other:
BEHAVIOR: Cooperative. Resistant. Tired. Paranoid. Anxious. Guarded. Defensive. Agitated, Impulsive. Withdrawn. Stereotyped. Hyperactive. Other:
SPEECH: Normal. Tangential. Pressured. Slowed. Rambling. Mute. Soft. Loud. Other:
MOOD: Euthymic. Euphoric. Dysthymic. Angry. Depressed. Irritable. Anxious. Hostile. Neutral. Elated. Apathetic
AFFECT: Appropriate. Manic. Blunted. Labile. Full. Constricted. Flat. Reactive. Restricted. Incongruent. Exaggerated.
THOUGHT PROCESS: Linear. Goal-Directed. Illogical. Disorganized. Poverty of Thought.
THOUGHT CONTENT: Intact. Flight of Ideas. Tangential. Blocking. Circumstantial. Loose.
PERCEPTIONS: Good. Fair. Poor
INSIGHT: Good. Fair. Poor.
JUDGMENT: Good. Fair. Poor.
COGNITION: Intact, Fair. Poor.
Language. WNL. Abnormal
MEMORY: None. Immediate. Recent. Remote.
C-SSRS (CURRENT)
1. WISH TO BE DEAD:
have you wished you were dead or wish you could go to sleep and not wake up? No
if yes, describe:
2. NON-SPECIFIC ACTIVE SUICIDAL THOUGHTS:
have you had any thoughts of killing yourself? No
if yes, describe:
3. ACTIVE SUICIDAL IDEATIONS WITH ANY METHODS (NOT PLAN) WITHOUT INTENT TO ACT
have you been thinking about how you might do this? No
if yes, describe:
4. ACTIVE SUICIDAL IDEATIONS WITH SOME INTENTS TO ACT, WITHOUT SPECIFIC PLAN
have you had these thoughts and had some intentions of acting on them? No
if yes, describe:
5.ACTIVE SUICIDAL IDEATIONS WITH SPECIFIC PLAN AND INTENT
have you start to work out or worked out the details of how to kill yourself? No
if yes, describe:
C-SSRS (LIFETIME)
1. WISH TO BE DEAD:
have you wished you were dead or wish you could go to sleep and not wake up? NO
if yes, describe:
2. NON-SPECIFIC ACTIVE SUICIDAL THOUGHTS: In the past, not now.
have you had any thoughts of killing yourself? NO
if yes, describe:
3. ACTIVE SUICIDAL IDEATIONS WITH ANY METHODS (NOT PLAN) WITHOUT INTENT TO ACT
have you been thinking about how you might do this? NO
if yes, describe:
4. ACTIVE SUICIDAL IDEATIONS WITH SOME INTENTS TO ACT, WITHOUT SPECIFIC PLAN.
have you had these thoughts and had some intentions of acting on them? NO
if yes, describe:
5.ACTIVE SUICIDAL IDEATIONS WITH SPECIFIC PLAN AND INTENT: NO
have you start to work out or worked out the details of how to kill yourself? NO
if yes, describe:
PROTECTIVE FACTORS:
RISK ASSESSMENT: Low
SAFETY PLAN RECOMMENDATIONS: TO CALL 911 IF FEELING SUICIDAL
Psychosis: Y/N No
Diagnosis Formulation:
Score on Administered Screening Tool: PHQ score 16/27,
Assessment:
The client is a 33-year-old Caucasian female seen via telehealth for initial psychiatric evaluation. She is currently in an inpatient treatment facility for substance abuse and will be discharged on the 4th of October 20123. The client stated that she wants to continue her treatment in an outpatient setting. The client abuses crack cocaine, Alcohol, and Marijuana. She noted that she “drinks to blackout” and that she makes bad decisions when under the influence of substances. She reported anxiety most of the day and also when she wakes up from sleep. She grew up with six siblings and a mother. Pt father was not in the house and he abused alcohol. Pt completed high school and cosmetology school. She reported sexual abuse by her cousin when she was a child and domestic violence from her male partners. she reported that her last partner kicked her in “the stomach and split my spleen” last year. She has three children from different men and the last child is 9 months old. She denied having flashbacks to those events but remembers them when she narrates the ordeal. She reported trouble sleeping and staying asleep and her appetite is good. she reported that she has gained some weight while in the inpatient treatment facility and attributed it partly to her meds. She is on a pre-trial release for 2nd-degree assault on another female. She noted that she has an anger management problem. Pts PHQ score is 16/27 while on anti-anxiety medication and her score on GAD is significant.
The patient will start Seroquel 150mg@ at bedtime for mood stability; she will continue Lexapro 10mg for Anxiety daily and Hydroxyzine PRN. The patient will start Topomax to reduce cravings for drugs. Pt will benefit from Psychotherapy to help build resilience and positive coping skills to manage anxiety and anger
Plan: The 90 plan is to reduce depression and anxiety symptoms
To continue substance abuse recovery.
Start psychotherapy. Call the office in 2 weeks if no appointment for psychotherapy is made.
Start with Seroquel 150mg at bedtime. Starts Lexapro 10 mg as needed. Start Topomax 25 mg daily. The patient is to report any medication S/E to the provider
Pt to send her discharge papers and lab results to the clinic
To call 911 if SI/HI/AH/VH.
Follow up in weeks.
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