Review this week’s Learning Resources and consider the insights they provide about assessing and diagnosing psychotic disorders. Consider whether experiences o

TRANSCRIPT OF VIDEO FILE: 

00:00:00______________________________________________________________________________ 

00:00:00BEGIN TRANSCRIPT: 

00:00:00[sil.] 

00:00:15OFF CAMERA Your roommates, Rachel and Liz, shared some information with me. They said that you were fine, and that shortly after your aunt died, that you started acting in a different sort of strange way. Started having thoughts and hearing things that others couldn't hear. 

00:00:35JESS They think I'm living in a movie. Rachel and Liz. That's who they think I am. I see a lot of movies. So maybe they're right. Maybe I am a movie 

00:00:45OFF CAMERA I'm not sure I understand how you can be a movie. 

00:00:45JESS Because they listen to our apartment. 

00:00:50[Whispers] 

00:00:50JESS They listen from next door. 

00:00:50OFF CAMERA Who listens? 

00:00:55JESS Russian men and whores. They drill all night long. That's how they send their information back. Drilling. 

00:01:05OFF CAMERA Drilling. They send messages by drilling? 

00:01:10JESS Doesn't surprise me. Most people don't understand. 

00:01:15OFF CAMERA Your roommates said that your favorite aunt that died, she's the one who raised you. 

00:01:20JESS Maybe she did. Maybe she didn't. Who told you? Can you prove it? I can't. 

00:01:30OFF CAMERA Liz and Rachel told me. 

00:01:30JESS Good for them. 

00:01:35OFF CAMERA And your roommates said you had some new neighbors that moved in. Are these the neighbors you're talking about? 

00:01:45JESS They're not neighbors. They're Russians. They don't answer their door. I tried to banging on their door and they didn't answer. Figures. I mean they only speak English. They don't speak English, they speak Russian in code. 

00:02:00OFF CAMERA You know, your roommate, Rachel, told me your new neighbors speak Spanish. They speak Spanish. 

00:02:10JESS They lie. But what do you expect? 

00:02:15OFF CAMERA What do they do? Your neighbors? 

00:02:20JESS I don't want to talk about this any more. 

00:02:25OFF CAMERA You know, Jess, I imagine what you are experiencing right now feels very frightening. I hear from a lot of the people who, hear voices that maybe aren't there, that it's very frightening. And it's upsetting. Are you experiencing anything like that? 

00:02:40JESS Yes. I hear them talking when no one else can. I mean not Rachel, not Liz. That's why I went down to my car yesterday. Because if I'm very, very still, the Russians can't code me. 

00:02:55OFF CAMERA What do you mean code you? 

00:03:00JESS You know. You act like you don't know, but you know. 

00:03:05OFF CAMERA How long did you stay in your car? 

00:03:10JESS Six hours. I watched them move in and out. 

00:03:15OFF CAMERA So do you sometimes see things that your roommates don't see? 

00:03:20JESS No. But I know things that they don't know. 

00:03:30OFF CAMERA Jess, I realize it is difficult sometimes for people to tell me things but it really helps me with their background. Has anything happened recently? Anything traumatic? 

00:03:40JESS I think that secret government papers are traumatic. Like blueprints. I mean, they have blueprints of buildings. My apartment is a building. 

00:03:55OFF CAMERA What are the blueprints? 

00:03:55JESS They're all over the walls. That's what they want. 

00:04:00OFF CAMERA The neighbors? 

00:04:00JESS The Russians. They're terrorists. You'll find out too late. 

00:04:10OFF CAMERA Has anyone else seen these blueprints Jess? 

00:04:10JESS I can stop them from seeing them. I covered the walls, I marked up the walls. I just need more markers. 

00:04:20OFF CAMERA Jess, do you drink alcohol or take drugs? 

00:04:25JESS My body is my temple. No. 

00:04:30OFF CAMERA Have you been taking any prescription medications? 

00:04:35JESS Yes I did. I was. 

00:04:40OFF CAMERA So you stopped taking your medications? 

00:04:45JESS Yes I stopped taking my medications. The medications were part of the problem. But you know all about that, don't you? 

00:04:55OFF CAMERA Jess, do you have any thoughts of hurting yourself, or hurting any other people? 

00:05:00JESS Rachel and Lizzy? I don't think they're in on it. Time will tell. 

00:05:10[sil.] 

00:05:10END TRANSCRIPT 

BEGIN TRANSCRIPT: 

00:00:00[sil.] 

00:00:15OFF CAMERA Ms. Branning, Mr. Nehring asked suggested you see me. He said your having some issues at work. 

00:00:20MS. BRANNING You could call them that. 

00:00:20OFF CAMERA What kind of difficulty are you having at work? 

00:00:25MS. BRANNING Well Mr. Nehring wants to fire me. 

00:00:30OFF CAMERA Why do you think Mr. Nehring wants to fire you? 

00:00:30MS. BRANNING Because Eric is in love with me. And it's probably getting in the way. And he wants to fire me. 

00:00:40OFF CAMERA Who is Eric? 

00:00:40MS. BRANNING Eric is my supervisor. 

00:00:45OFF CAMERA Are the two of you in a relationship? 

00:00:45MS. BRANNING No! Eric has his own girlfriend, I have my own boyfriend. But Mr. Nehring got it in his head that this is my fault. And they've been ganging up against me. 

00:01:00OFF CAMERA What happened to make you feel this way? 

00:01:00MS. BRANNING Eric is lustful for me. Lust. Lustful. 

00:01:10OFF CAMERA Well has Eric done anything inappropriate? 

00:01:10MS. BRANNING No, he doesn't have to. 

00:01:15OFF CAMERA What do you mean? 

00:01:15MS. BRANNING Well, he has this way of walking toward me and he gives me the easiest assignments to do and he asks me to voice my opinion a lot in our weekly meetings. And I'm beautiful. I mean, not to be boastful or anything but I'm a strong woman. And people are attracted to that. And others, like Mr. Nehring feel threatened by it. He probably feels I could replace him in a couple years. And I could. 

00:01:45OFF CAMERA But there have been no instances of sexual harassment. 

00:01:50MS. BRANNING No. And now they want to fire me, and it's probably because they don't want me to get in the way of their day. I'm probably a distraction or something. 

00:02:00OFF CAMERA According to Mr. Nehring you haven't made a sale in three weeks. 

00:02:05MS. BRANNING Oh, it's been a slow time period. I guess it wouldn't be bad thing if they fired me. I mean after all of this, all the bad it's done for my health. You know I should really sue for discrimination, you know the stress and the health problems. 

00:02:25OFF CAMERA You've been having health problems? 

00:02:25MS. BRANNING Yes. Yes. It keeps getting worse. 

00:02:30OFF CAMERA Can you describe it for me? 

00:02:30MS. BRANNING Well you know there's this pain in my neck, it aches, it spreads to my back, I think there's a lump, right here. I'm really worried. 

00:02:55OFF CAMERA And what do you feel is the cause? 

00:02:55MS. BRANNING I told you, pain, suffering, broken heart. I think it's cancer. 

00:03:05OFF CAMERA Have you been seen by a doctor? 

00:03:10MS. BRANNING No. But it's probably cancer. And it's slowly killing me. And it's all because of them. And Eric's obsession with me. 

00:03:20OFF CAMERA Ms Branning, I don't think you have to worry, a broken heart can't cause cancer. 

00:03:25MS. BRANNING You never know until it happens. 

00:03:30[sil.] 

00:03:30END TRANSCRIPT 

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NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation 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

© 2021 Walden University Page 1 of 3

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NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Exemplar

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).

A ssessment

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.

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