PRAC 6645 WEEK 4 Comprehensive Psychiatric Evaluation Note and Patient Case Presentation, Part 1
Subjective:
CC (chief complaint): “I have been diagnosed with MDD, GAD, PTSD, DID, and ADHD related to Bipolar.”
HPI: A.A is a 28-year-old female who presented with reports that she has been diagnosed with MDD, GAD, PTSD, DID, and ADHD related to Bipolar. She reports that she has been admitted 3-4 times because of depression. She was last hospitalized on 18th September 2022 after accidentally overdosing on cocaine and was raped when she overdosed. She mentions that she had been sober for five months from alcohol and cocaine. However, she had a relapse in February 2024. She reports that her former therapist, Elizabeth, was the best therapist she ever encountered since she taught her about magical thinking. The patient lost her private insurance and now needs a new therapist. She states that a year ago, she visited an EMDR therapist but did not have therapy with the therapist. The patient reports wanting to attend individual therapy and be referred for medical evaluation.
Past Psychiatric History:
- General Statement: History of MDD, GAD, PTSD, DID, ADHD, alcohol use disorder, and cocaine use.
- Caregivers (if applicable): None
- Hospitalizations: 3-4 times for depression; Last admission was 18th September 2022 due to a Cocaine overdose.
- Medication trials: None
- Psychotherapy or Previous Psychiatric Diagnosis: MDD, GAD, PTSD, DID, ADHD, alcohol use disorder, and cocaine use
Substance Current Use and History: Positive history of alcohol use disorder and cocaine use. She admits to smoking cigarettes and vaping.
Family Psychiatric/Substance Use History: The patient’s 24-year-old sister was sexually and physically abused by their stepfather at the age of 5-10 years.
Psychosocial History: The patient has a daughter and states she gets along with her daughter’s father, Kevin, although they are not together. However, she states that Kevin can be verbally abusive. She reports that she has no current significant other. She states that she loves being a mother to her daughter. She mentions that she remembers minimal about her childhood, probably due to trauma. The patient’s father and mother have a poor relationship.
Medical History: Positive for Thyroid problem; Reports sleep apnea.
- Current Medications: None
- Allergies: None
- Reproductive Hx: Para 1+0
Objective:
Diagnostic results: No tests were administered.
Assessment:
Mental Status Examination:
The patient is oriented to person, place, and time. The self-reported mood is anxious, and affect is constricted. Her speech is clear and goal-directed. She has a coherent thought process. No evident hallucinations or delusions. She denies current suicidal or homicidal ideations. She has good short and long-tem memory. She demonstrates good abstract thought and judgment. Insight is present.
Differential Diagnoses:
- F33. 2 Major Depressive Disorder (MDD), recurrent severe, without psychotic features Persons with MDD present with a sad or depressed mood or a lack of interest in activities. They often exhibit signs of inattention, fatigue, loss of energy, concentration difficulties, and appetite disturbance (Christensen et al., 2020). MDD was chosen because the patient has a history of depression.
- F41.1 Generalized Anxiety Disorder (GAD): Adults with GAD often exhibit hyperactive behavior, like fidgeting and inattentive behaviors. These behaviors are usually accompanied by persistent fear and worries and somatic symptoms of anxiety (Mishra & Varma, 2023). The patient has a history of GAD and the reported mood is anxious, making this a differential diagnosis.
- F90. 2 Attention-deficit/hyperactivity disorder (ADHD), Combined type: The clinical manifestation of ADHD in adults includes difficulty getting started on tasks, variable attention to detail, difficulties with self-organization and prioritization, and poor persistence in tasks that require sustained mental effort (Sapkale & Sawal, 2023). This is a differential diagnosis owing to the patient’s history of ADHD.
- F43.10 Post-traumatic stress disorder (PTSD): PTSD is a syndrome that is linked to exposure to a real or threatened injury or assault. It manifests with intrusive thoughts, avoidance of associated stimuli, negative alterations in mood, and alterations in arousal (El-Mallakh, 2020). The patient reports a history of PTSD, making this a probable diagnosis.
Reflections: In a different patient evaluation, I would ask the patient about her depression and anxiety symptoms. I would probe on when she last experienced a constant sad mood or anxiety symptoms. I would also ask what she does when she experiences depression and anxiety, including coping strategies (Carlat, 2024). Factors associated with poor mental health outcomes like depression and anxiety disorders include low household income, low educational attainment, unemployment, and social isolation (Prokosch et al., 2022). Thus, it is crucial to ask the patient about her source and level of income, education level, and living status to determine if they could be resulting in her poor mental health. Health promotion should include educating the patient on available community resources for persons with mental health disorders, including community therapy programs and support groups.
Case Formulation and Treatment Plan:
Treatment goals: Decrease depression, anxiety, PTSD, ADHD, DID, and PMDD symptoms.
Treatment Objectives: Attend therapy and medication visits and adhere to medication as prescribed.
Treatment interventions: Individual CBT and medication management as needed for 3-6 months. CBT is recommended for persons with depression because it helps alleviate symptoms of depression as an independent therapy or in combination with medications. It achieves this by modifying the underlying schemas or beliefs that maintain the depression (Gautam et al., 2020). Besides, it helps to address various psychosocial problems, like, marital discord, job stress which contribute to depressive symptoms
Referral: Refer to a psychiatrist for medication review if symptoms do not improve with psychotherapy.
Follow-up: Follow-up after four weeks to assess progress with treatment and identify any concerns requiring further treatment.
I confirm the patient used for this assignment is a patient that was seen and managed by the student at their Meditrek approved clinical site during this quarter course of learning.
Preceptor signature: ________________________________________________________
Date: ________________________
References
Carlat, D. J. (2024). The Psychiatric Interview (5th ed.). Wolters Kluwer.
Christensen, M. C., Wong, C. M. J., & Baune, B. T. (2020). Symptoms of Major Depressive Disorder and Their Impact on Psychosocial Functioning in the Different Phases of the Disease: Do the Perspectives of Patients and Healthcare Providers Differ?. Frontiers in Psychiatry, 11, 280. https://doi.org/10.3389/fpsyt.2020.00280
El-Mallakh, R. S. (2020). Posttraumatic stress disorder: from pathophysiology to pharmacology. Current Psychiatry, 19(5), 33-39.
Gautam, M., Tripathi, A., Deshmukh, D., & Gaur, M. (2020). Cognitive Behavioral Therapy for Depression. Indian Journal of Psychiatry, 62(Suppl 2), S223–S229. https://doi.org/10.4103/psychiatry.IndianJPsychiatry_772_19
Mishra, A. K., & Varma, A. R. (2023). A Comprehensive Review of the Generalized Anxiety Disorder. Cureus, 15(9), e46115. https://doi.org/10.7759/cureus.46115
Prokosch, C., Fertig, A. R., Ojebuoboh, A. R., Trofholz, A. C., Baird, M., Young, M., De Brito, J. N., Kunin-Batson, A., & Berge, J. M. (2022). Exploring associations between social determinants of health and mental health outcomes in families from socioeconomically and racially and ethnically diverse households. Preventive Medicine, 161, 107150. https://doi.org/10.1016/j.ypmed.2022.107150
Sapkale, B., & Sawal, A. (2023). Attention Deficit Hyperactivity Disorder (ADHD) Causes and Diagnosis in Adults: A Review. Cureus, 15(11), e49144. https://doi.org/10.7759/cureus.49144
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Comprehensive Psychiatric Evaluation Note and Patient Case Presentation, Part 1
Psychiatric notes are a way to reflect on your practicum experiences and connect them to the didactic learning you gain from your NRNP courses. 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 in a group setting during the last 4 weeks, using the Comprehensive Psychiatric Evaluation Note 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.
Learning Resources
Required Readings
- Links to an external site. (2007–2020). Practice guidelines for group psychotherapy. https://www.agpa.org/home/practice-resources/practice-guidelines-for-group-psychotherapy
- American Psychiatric Association.
- Links to an external site. (2020). Clinical practice guidelines. https://psychiatryonline.org/guidelines
- Carlat, D. J. (2024). The psychiatric interview (5th ed.). Wolters Kluwer.
- Chapter 24, “Assessing Mood Disorders I: Depressive Disorders”
- Chapter 25, “Assessing Mood Disorders II: Bipolar Disorders”
- Meditrek
- Links 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. - National Institute for Health and Care Excellence
- Links to an external site.
https://www.nice.org.uk/ - U.S. Department of Veterans Affairs. (2020). VA/DoD clinical practice guidelines.
- Links to an external site. https://www.healthquality.va.gov/
- 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)
- Tutorial: Kaltura Media Uploader
Required Media
- Center for Reality Therapy. (2010). Counseling with a group of not so eager clients [Video].
- Links to an external site. https://go.openathens.net/redirector/waldenu.edu?url=https://video.alexanderstreet.com/watch/counseling-with-a-group-of-not-so-eager-clients
- College of Nurses of Ontario CNO. (2018). Therapeutic nurse-client relationship: Maintaining boundaries [Video]. YouTube.
- Links to an external site. https://www.youtube.com/watch?v=mCgmyyiZ9ek
To Prepare
- Review this week’s Learning Resources and consider the insights they provide about clinical practice guidelines.
- Select a group patient for whom you conducted psychotherapy for a mood disorderduring the last 4 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. All psychiatric evaluation notes must be signed by your Preceptor. When you submit your note, you should include the complete comprehensive psychiatric evaluation note as a Word document and pdf/images the completed assignment signed by your Preceptor. You must submit your note 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 Grading Policy. - Then, based on your evaluation of this patient, develop a video presentation of the case. Plan your presentation using the Assignment rubric and rehearse what you plan to say. Be sure to review the Kalturasupport resources in the Classroom Support Center found by clicking on the Help
- Include at least five scholarly resources to support your assessment and diagnostic reasoning.
- Ensure that you have the appropriate lighting and equipment to record the presentation.
The 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 complex case study. Be succinct in your presentation, and do not exceed 8 minutes. 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.
By Day 7
Submit your Video and Comprehensive Psychiatric Evaluation Note. You must submit two files for the evaluation note, including a Word document and scanned pdf/images the completed assignment signed by your Preceptor.
submission information – Part 1: Recording
To submit your video response entry:
- Click on Start Assignment near the top of the page.
- Next, click Text Entry and then click the Embed Kaltura Media button.
- Select your recorded video under My Media.
- Check the box for the End-User License Agreement and select Submit Assignment for review.
submission information – Part 2: Comprehensive Psychiatric Evaluation Note
To submit Part 2 of this Assignment, click on the following link:
Rubric
PRAC_6645_Week4_Assignment2_PT1_Rubric
| Criteria | Ratings | Pts | ||||
|---|---|---|---|---|---|---|
| This criterion is linked to a Learning Outcome Photo ID display and professional attire |
|
5 pts | ||||
| This criterion is linked to a Learning Outcome Time |
|
5 pts | ||||
| This criterion is linked to a Learning Outcome Discuss Subjective data:• Chief complaint• History of present illness (HPI)• Medications• Psychotherapy or previous psychiatric diagnosis• Pertinent histories and/or ROS |
|
10 pts | ||||
| This criterion is linked to a Learning Outcome Discuss Objective data:• 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 |
|
10 pts | ||||
| This criterion is linked to a Learning Outcome Discuss results of Assessment:• Results of the mental status examination• 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 diagnostic criteria and is supported by the patient’s symptoms. |
|
20 pts | ||||
| This criterion is linked to a Learning Outcome Discuss treatment Plan:• A treatment plan for the patient that addresses psychotherapy and rationales including a plan for follow-up parameters and referrals |
|
20 pts | ||||
| This criterion is linked to a Learning Outcome Presentation style |
|
5 pts | ||||
| Total Points: 75 | ||||||
