WEEK 7: COMPREHENSIVE PSYCHIATRIC EVALUATION NOTE AND PATIENT CASE PRESENTATION
This assignment is a graduate level Masters in Nursing Psychiatric Nurse Practitioner program, and the work should be reflective of the highest standards of graduate work.
Please use APA 7 format only. Please use at least 5 USA based peer-reviewed evidence-based articles in the past 5 years for references. Per our NP program; All discussions and assignments require supportive evidence which must be based on scholarly sources only, NOT dictionaries, encyclopedias, newspapers, commercial journals or public websites which will not be accepted. Examples of sources that are not acceptable include Stat Pearls, Mayo Clinic, GoodTherapy, etc.
Generally, literature that is cited should not be older than five years unless it is considered a classical work.
Below is patient information for this assignment, The assignment instructions and the template to use for the assignment also attached.
Please let me know if you have any questions. Thank you in advance.
Tanya.
The patient information for impulse control /conduct disorder assignment:
B.W. is 9 year-old male, present to clinic w/mom
Was seen by pediatrician, and filled questioniare and MD suggested
Pt is not getting along with other kids in school. Always causing trouble in school. Dad not in his life for 4 years now, incarcerated.
He had normal delivery. Lives with mom and dad, until 2 years, then dad incarcerated, came out, then at 5 years old in 2019, dad was incarcerated again.
Pt in 4th grade, said he doesn’t like school, making As and some B. best subject is Math and worse is Science. Pt reports been bully in 3rd grade but not anymore. He participate in bulling others as well. Have 2 friends. Mom said teacher told her pt have difficulty making friend bcoz he is difficult to get along with. He sit alone in separate sit away from other kids.
No allergies and no med hx
On father side – uncle with mental illness
Denies physical or sexual abuse
Sleep- at home can’t sleep well, wakes up middle of night, have night sweats
Happiness Scale 0-10 At home 6/10 and at school 5/10
Pt not happy because dad is not home w/him. Also thinking of stuff that makes him paranoid, d/t watching scary videos at night.
Pt lives at home with mom, 2 cousins and aunt. Sometimes stayed at grandparents home. Pt report fair appetite and grand parents home, but great appetite at home. Pt does not like going to grandparent home. He is very upset about that.
Pt states he is very active, he plays basketball and football. Pt want to be professional NBA or NFL player, if not an engineer.
Pt denies feeling bad, but mom feels he lack confident in himself.
Plan –Start therapy to teach him positive coping skills, build confident
Dx: Adjustment Disorder and Generalized Anxiety Disorder
Subjective:
Patient is 9 year old male (4th grade) with no PMH, daily medications, NKDA seen today via telehealth with consent for initial psychiatric evaluation. Mother states that the son is having trouble adjusting at home and school. The mother states that he is not listening and is having a lot of difficulty at school. States that the teacher states he is having difficulty making friends, she has to move him around in the classroom because he is bothering others, and he keeps a messy area. Patient states that he is having trouble because he misses his dad that been basically incarcerated since he was 2 years. He grew up with his mother and he is the only child. They live with an aunt and 2 cousins currently. He recently has moved with the grandparents and is very sad about it because of his behavior and needing a male role model. He states that he is sad at home and at school, is eating less at the grandparents’ house. Patient states that he has being there and just wants to be with his mother. Patient denies physical/verbal/sexual abuse, states he only gets in trouble when he is “bad”.
Objective: Mental Status Examination
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: Within 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.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 A SPECIFIC PLAN AND INTENT
Have you started 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; No – Denies
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?
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: Self-mutilating. Cutting wrist
4. ACTIVE SUICIDAL IDEATIONS WITH SOME INTENT TO ACT, WITHOUT SPECIFIC PLAN.
have you had these thoughts and had some intentions of acting on them? NO
if yes, describe: Cutting wrist
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: Mother
RISK ASSESSMENT: Low
SAFETY PLAN RECOMMENDATIONS: CALL 911 IF FEELING SUICIDAL
Psychosis: Y/N
Diagnosis Formulation:
Score on Administered Screening Tool: PHQ score 9/27.
Assessment:
Patient is having difficulty making friends. He is getting trouble in school, he is waking up in the middle of night, unable to stay asleep for a full night, and is angry that his father is incarcerated. He recently is spending more times with grandparents which is making him unhappy. His appetite is decreased. During the encounter the patient is experiencing moments of crying, being sad, and looking away. Happiness scale 6/10 (home) 5/10 (school). He is having difficulty adjusting in school and home with his behavior and to routines.
Patient/family educated on :
building self-confidence with positive self talk and reward system for appropriate modeled behaviors
continue physical/outdoor activities, puzzles, and mind games to help with feelings of sadness
keeping a journal of sleep habits and sleep times to help establish sleep hygiene
Initiate psychotherapy to help building positive coping skills.
Safety plan 911/988 if SI/HI, auditory/visual/tactile disturbances
Mother educated on creating a reward system for son with clear expectations.
Plan:
The plan is in 90 days pt will have decreased impulsivity and sadness
Pt will start therapy
Pt to keep a journal on daily sleep
The PT is to continue sporting activity
The Assignment instructions:
COMPREHENSIVE PSYCHIATRIC EVALUATION NOTE
Psychiatric notes are a way to reflect on your practicum experiences and connect the experiences to the learning you gain from your weekly Learning Resources. Comprehensive psychiatric evaluation 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 at your practicum site, using the Comprehensive Psychiatric Evaluation Note Template provided.
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 disorder during 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. 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. 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.
Include at least five scholarly resources to support your assessment and diagnostic reasoning.
THE ASSIGNMENT
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.
Learning Resourses:
Required Reading:
• Document: Comprehensive Psychiatric Evaluation Note Template (Word document)Download Comprehensive Psychiatric Evaluation Note Template (Word document)
• Document: Comprehensive Psychiatric Evaluation Note Exemplar (Word document)Download Comprehensive Psychiatric Evaluation Note Exemplar (Word document)
Required Media:
• Classroom ProductionsLinks to an external site.. (Producer). (2016). Impulse and conduct disorders [Video]. Walden University.
• Professor Hartung. (2020). Multisystemic therapy (MST) for at-risk youth and juveniles informational webinarLinks to an external site. [Video]. YouTube. https://www.youtube.com/watch?v=yHbTEWCDlpE
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