Comprehensive Psychiatric Evaluation and Patient Case Presentation
Assignment 2: Comprehensive Psychiatric Evaluation and Patient Case Presentation
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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.
To Prepare
• Review this week’s Learning Resources and consider the insights they provide about assessment and diagnosis. Also review the Kaltura Media Uploader resource in the left-hand navigation of the classroom for help creating your self-recorded Kaltura video.
• 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. All psychiatric evaluations must be signed, and each page must be initialed by your Preceptor. When you submit your document, you should include the complete Comprehensive Psychiatric Evaluation as a Word document, as well as a PDF/images of each page that is initialed and signed by your Preceptor. You must submit your document using SafeAssign.
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 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.
• Ensure that you have the appropriate lighting and equipment to record the presentation.
Assignment
Record yourself presenting the complex case for your clinical patient. In your presentation:
• Dress professionally with a lab coat 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?
By Day 7
Submit your Video and Comprehensive Psychiatric Evaluation. You must submit two (2) files for the evaluation, including a Word document and scanned PDF/images of each page that is initialed and signed by your Preceptor.
Case study
atient Demographics:
Patient Name: William Hardin
Age:53
Sex (M/F/Trans M/Trans F/Non-Binary): male
Hospital Name and Location (include unit): DHOA ED
Clinical Information:
Legal Status (Voluntary/Involuntary, Initiated by whom): 1013
Psych Diagnosis: Major Depressive Disorder
Patient is a 53 year old male on ED MD 1013 due to suicidal ideations, depression and anxiety. Pt reports he is diagnosed with PTSD due to being shot and finding his dad after he had a heart attack and PT picked him up and carried him in to get help. PT reports he has depression, anxiety, and anger issues. PT reports he is separated from his wife and kids so he does not have supports. PT reports he used to traffic drugs. PT
endorses he is angry and turned to drugs and alcohol to cope. PT reports he gone to Serenity in the past and was taking Seroquel. That helped PT sleep because PT has
night terrors. PT reports he is out of medications 6 months. PT reports he has not been sleeping. PT endorses SI/HI. PT reports he could overdose or crash his car. PT
endorses HI towards the people who caused him and his wife to separate.
CSSR Result: High Risk
Calm and cooperative? Yes
Recent Aggression? If yes towards whom? With intent to harm? No
Restraints in the past 24 hours (if yes include reason/times): none
Psych history (Past treatment and current meds/med compliance): yes
Is the patient able to participate in treatment? Yes
Medical:
Medical Conditions: Diabetes and stints from heart attack
Relevant Psych Medications Given if in the ED: Celexa and Seroquel
Is the patient ambulatory (if no, details on any wheelchair/crutches/etc needed): yes
Any issues needed with ADLs: no
More than a 1 person assist?: No
Labs within normal limits (if no explain): within normal limits
Any medical devices or attachments (02, CPAP, BIPAP, Bags, Tubes, Foleys, etc): No
IV medications: none
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