Comprehensive Psychiatric Evaluation and Patient Case Presentation, Video Case Presentation

Comprehensive Psychiatric Evaluation and Patient Case Presentation, Video Case Presentation
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 5 weeks, using the Comprehensive Psychiatric Evaluation Template provided. You will then use this note to develop and record a case presentation for this patient.

Resources

Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.

WEEKLY RESOURCE

To Prepare
Select a patient that you examined during the last 5 weeks. Review prior resources on the disorder this patient has.
It is recommended that you use the Kaltura Media tool to record and upload your assignment.
Review the Kaltura Media resource in the Classroom Support Center area (accessed via the Help button).
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. You will submit your document in Week 5 Assignment, Part 2 area and you will include the complete Comprehensive Psychiatric Evaluation as well as have your preceptor sign the completed assignment. You must submit your documents 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 Late Policies.
Develop a video case presentation, based on your progress note 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 5: Assignment, Part 2 you will submit two (2) files for the Comprehensive Psychiatric Evaluation, including a Word document and scanned PDF/images of the completed assignment signed by your Preceptor.

submission information

1. Click on Start Assignment near the top of the page.
2. Next, click Text Entry and then click the Embed Kaltura Media button.
3. Select your recorded video under My Media.
4. Check the box for the End-User License Agreement and select Submit Assignment for review.

Rubric
PRAC_6635_Week5_Assignment2_Part1_Rubric
PRAC_6635_Week5_Assignment2_Part1_Rubric
Criteria Ratings Pts
This criterion is linked to a Learning OutcomePhoto ID display and professional attire
5 to >0.0 pts
Excellent
Photo ID is displayed. The student is dressed professionally.
0 pts
Poor
Photo ID is not displayed. Student must remedy this before grade is posted. The student is not dressed professionally.
5 pts
This criterion is linked to a Learning OutcomeTime
5 to >0.0 pts
Excellent
The video does not exceed the 8-minute time limit.
0 pts
Poor
The video exceeds the 8-minute time limit. (Note: Information presented after the 8 minutes will not be evaluated for grade inclusion.)
5 pts
This criterion is linked to a Learning OutcomeDescription of chief complaint and history of present illness
5 to >4.0 pts
Excellent
The student provides an accurate, clear, and complete description of the chief complaint and history of present illness.
4 to >3.0 pts
Good
The student provides an accurate description of the chief complaint and history of present illness.
3 to >1.0 pts
Fair
The student provides a vague, inaccurate, or incomplete description of the chief complaint and history of present illness, or description is missing.
1 to >0 pts
Poor
The student provides a completely inaccurate, or incomplete description of the chief complaint and history of present illness, or the description is missing.
5 pts
This criterion is linked to a Learning OutcomeDescription of past psychiatric, substance use, medical, social, and family history
5 to >4.0 pts
Excellent
The student provides an accurate, clear, and complete description of past psychiatric, substance use, medical, social, and family history.
4 to >3.0 pts
Good
The student provides an accurate description of past psychiatric, substance use, medical, social, and family history.
3 to >1.0 pts
Fair
The student provides a vague, inaccurate, or incomplete description of psychiatric, substance use, medical, social, and family history, or description is missing.
1 to >0 pts
Poor
The student provides a completely inaccurate, or incomplete description of psychiatric, substance use, medical, social, and family history, or description is missing.
5 pts
This criterion is linked to a Learning OutcomeDiscussion of most recent mental status exam and observations made during interview and review of systems
15 to >13.0 pts
Excellent
The student provides an accurate, clear, and complete discussion of results from most recent mental status exam and observations made during interview and review of systems.
13 to >11.0 pts
Good
The student provides an accurate discussion of results from most recent mental status exam and observations made during interview and review of systems.
11 to >10.0 pts
Fair
The student provides a vague, inaccurate, or incomplete discussion of results from most recent mental status exam and observations made during interview and review of systems.
10 to >0 pts
Poor
All or most of the discussion is inaccurate or missing.
15 pts
This criterion is linked to a Learning OutcomeDiscussion of diagnostics with results
10 to >8.0 pts
Excellent
The student provides an accurate, clear, and complete discussion of diagnostics with results.
8 to >7.0 pts
Good
The student provides an accurate discussion of diagnostics with results.
7 to >6.0 pts
Fair
The student provides a vague, inaccurate, or incomplete discussion of diagnostics with results.
6 to >0 pts
Poor
All or most of the discussion is inaccurate or missing.
10 pts
This criterion is linked to a Learning OutcomeDiagnostic Impression with three (3) differential diagnosesReflection on this case
25 to >22.0 pts
Excellent
The student provides an accurate, clear, and complete diagnostic impression with three (3) differentials….Reflections are thorough, thoughtful, and demonstrate critical thinking. …Reflections contain all 3 elements from the assignment directions.
22 to >19.0 pts
Good
The student provides an accurate diagnostic impression with three (3) differentials. …Reflections demonstrate critical thinking. …Reflections contain 2 of the elements from the assignment directions.
19 to >17.0 pts
Fair
The student provides a vague, inaccurate, less than 3, or incomplete diagnostic impression with differentials…. Reflections are somewhat general or do not demonstrate critical thinking…. Reflections contain 1 of the required elements from the assignment directions.
17 to >0 pts
Poor
All or most of the discussion is inaccurate or missing. No diagnostic impression and less than 2 differential diagnoses…. Reflections are incomplete, inaccurate, or missing. … There are no Reflections elements from the assignment directions.
25 pts
This criterion is linked to a Learning OutcomePresentation style
5 to >4.0 pts
Excellent
Presentation style is exceptionally clear, professional, and focused.
4 to >3.0 pts
Good
Presentation style is clear, professional, and focused.
3 to >2.0 pts
Fair
Presentation style is mostly clear, professional, and focused
2 to >0 pts
Poor
Presentation style is unclear, unprofessional, and/or unfocused.
5 pts
Total Points: 75
Notes: This VD a 40-year-old African American woman AOX4 is seeking counseling and an initial mental health assessment. The patient explains becoming more and more irritable, furious, and suspicious of other people. She expresses unhappiness with her existing relationships by stating that “people be fake” and that she feels overwhelmed. She has a boyfriend, but their connection seems unstable, and she lives alone. In the tenth grade, she dropped out of school. She appears casually dressed, adequate hygiene,agitated, uses profane language Speech is normal and clear. Displaying a lot of anger.
She claims to have had numerous psychiatric hospitalizations throughout her childhood and to have been diagnosed with bipolar disorder at the age of 7, Denies being placed on Psychotropics. She exhibits significant resistance to pharmacological treatment and denies currently taking any mental drugs.
The patient has a history of severe trauma, including not knowing her father and the loss of her mother when she was eleven years old.She alleged to have learned that her maternal grandma suffered from bipolar disorder and that her paternal grandmother has mental health problems. At the age of nine, her older sister was also diagnosed with bipolar disorder.
She professes to have had several run-ins with the justice system for crimes and to have a history of legal problems. She denies having any other significant medical history, however she does recall having surgery to remove a gunshot from her groin.Severe mood disorder, inadequate impulse control, and a high risk of interpersonal conflict are all present in the patient. She currently refuses to take medication and shows little understanding of her condition. Bipolar disorder has been diagnosed for a long time and runs strongly in the family. Her emotional instability is brought on by trauma-related and psychological factors. Offer a plan Encourage a thorough mental health assessment, reconsideration of medications, and the potential initiation of a mood stabilizer. Begin weekly individual therapy with a focus on trauma-informed care, anger management, and mood regulation.At the time of the visit, there were no immediate thoughts of murdering someone. continue monitoring for growing thoughts of hurting oneself or other people.
The patient expressed awareness of the safety method but declined to participate completely at this time. Plan a follow-up for a week or if the situation worsens.

Patient Number 10
Client Information VD
Visit Information Shadowing
Practice Management Intake
Diagnosis Bipolar Mania, Schizoaffective disorder, Obsessive Compulsive disorder.
Student Notes A 40-year-old African American woman named VD comes in for a preliminary mental health assessment and therapy. She claims to be becoming more irritable, angry, and wary of other people. She expresses discontent with her social connections and calls individuals “fake.” VD seems stressed by her present situation.

The patient has a lengthy history of mental health issues, including several hospital stays during infancy and an early bipolar disorder diagnosis at age 7. She claims she has never been prescribed psychiatric drugs and denies using them at the moment. She currently prefers counseling over pharmaceutical treatment because she is resistive to it.She acknowledges a history of severe trauma, which includes the death of her mother when she was eleven years old and the fact that she has no relationship with her biological father. VD describes a family history of mental illness, including her paternal grandmother’s unknown mental health conditions and her maternal grandmother’s and older sister’s bipolar disorder (diagnosed at age 9).

She currently lives alone after quitting school in the tenth grade. Although their relationship is characterized as chaotic, she does have a boyfriend.She is dressed casually and maintains proper hygiene, and her appearance is suitable for her age and the time of year. She is agitated and frequently uses foul language. Outraged during the interview, no suicidal or homicidal thoughts, hallucinations, or delusions were observed. Because of their high level of emotional response, she’s not completely focused Seems easily distracted during the interview.

This is the patient

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