COMPREHENSIVE PSYCHIATRIC EVALUATION NOTE AND PATIENT CASE PRESENTATION
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.(Comprehensive Psychiatric Evaluation Note and Patient Case Presentation Essay)
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.(Comprehensive Psychiatric Evaluation Note and Patient Case Presentation Essay)
RESOURCES
Be sure to review the Learning Resources before completing this activity. Click the weekly resources link to access the resources.
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 disorder during 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, and each page must be initialed by your Preceptor. When you submit your note, you should include the complete comprehensive psychiatric evaluation note as a Word document and pdf/images of each page that is initialed and 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 Kaltura support resources in the Classroom Support Center found by clicking on the Help button.(Comprehensive Psychiatric Evaluation Note and Patient Case Presentation Essay)
- 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. (Comprehensive Psychiatric Evaluation Note and Patient Case Presentation Essay)
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?(Comprehensive Psychiatric Evaluation Note and Patient Case Presentation Essay)
- 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?(Comprehensive Psychiatric Evaluation Note and Patient Case Presentation Essay)
- 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 of each page that is initialed and 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_Rubric (1)
PRAC_6645_Week4_Assignment2_Rubric (1)
CriteriaRatingsPts
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 >3.0 pts
Excellent
The video does not exceed the 8-minute time limit.
3 to >0.0 pts
Good
The video exceeds the 8-minute time limit. (Note: Information presented after 8 minutes will not be evaluated for grade inclusion.)
0 pts
Fair
0 pts
Poor
5 pts
This criterion is linked to a Learning OutcomeDiscuss Subjective data:• Chief complaint• History of present illness (HPI)• Medications• Psychotherapy or previous psychiatric diagnosis• Pertinent histories and/or ROS(Comprehensive Psychiatric Evaluation Note and Patient Case Presentation Essay)
10 to >8.0 pts
Excellent
The video accurately and concisely presents the patient’s subjective complaint, history of present illness, medications, psychotherapy or previous psychiatric diagnosis, and pertinent histories and/or review of systems that would inform a differential diagnosis.(Comprehensive Psychiatric Evaluation Note and Patient Case Presentation Essay)
8 to >7.0 pts
Good
The video accurately presents the patient’s subjective complaint, history of present illness, medications, psychotherapy or previous psychiatric diagnosis, and pertinent histories and/or review of systems that would inform a differential diagnosis.
7 to >6.0 pts
Fair
The video presents the patient’s subjective complaint, history of present illness, medications, psychotherapy or previous psychiatric diagnosis, and pertinent histories and/or review of systems that would inform a differential diagnosis, but is somewhat vague or contains minor inaccuracies.(Comprehensive Psychiatric Evaluation Note and Patient Case Presentation Essay)
6 to >0 pts
Poor
The video presents an incomplete, inaccurate, or unnecessarily detailed/verbose description of the patient’s subjective complaint, history of present illness, medications, psychotherapy or previous psychiatric diagnosis, and pertinent histories and/or review of systems that would inform a differential diagnosis. Or subjective documentation is missing.
10 pts
This criterion is linked to a Learning OutcomeDiscuss 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 to >8.0 pts
Excellent
The video accurately and concisely documents the patient’s physical exam for pertinent systems. Pertinent diagnostic tests and their results are documented, as applicable.(Comprehensive Psychiatric Evaluation Note and Patient Case Presentation Essay)
8 to >7.0 pts
Good
The response accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are documented, as applicable.
7 to >6.0 pts
Fair
Documentation of the patient’s physical exam is somewhat vague or contains minor inaccuracies. Diagnostic tests and their results are documented but contain inaccuracies.(Comprehensive Psychiatric Evaluation Note and Patient Case Presentation Essay)
6 to >0 pts
Poor
The response provides incomplete, inaccurate, or unnecessarily detailed/verbose documentation of the patient’s physical exam. Systems may have been unnecessarily reviewed, or objective documentation is missing.
10 pts
This criterion is linked to a Learning OutcomeDiscuss 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.(Comprehensive Psychiatric Evaluation Note and Patient Case Presentation Essay)
20 to >17.0 pts
Excellent
The video accurately documents the results of the mental status exam…. Video presents at least three differentials in order of priority for a differential diagnosis of the patient, and a rationale for their selection. Response justifies the primary diagnosis and how it aligns with DSM-5 criteria.(Comprehensive Psychiatric Evaluation Note and Patient Case Presentation Essay)
17 to >15.0 pts
Good
The video adequately documents the results of the mental status exam…. Video presents three differentials for the patient and a rationale for their selection. Response adequately justifies the primary diagnosis and how it aligns with DSM-5 criteria.
15 to >13.0 pts
Fair
The video presents the results of the mental status exam, with some vagueness or inaccuracy…. Video presents three differentials for the patient and a rationale for their selection. Response somewhat vaguely justifies the primary diagnosis and how it aligns with DSM-5 criteria.(Comprehensive Psychiatric Evaluation Note and Patient Case Presentation Essay)
13 to >0 pts
Poor
The response provides an incomplete, inaccurate, or unnecessarily detailed/verbose description of the results of the mental status exam and explanation of the differential diagnoses. Or assessment documentation is missing.(Comprehensive Psychiatric Evaluation Note and Patient Case Presentation Essay)
20 pts
This criterion is linked to a Learning OutcomeDiscuss treatment Plan:• A treatment plan for the patient that addresses psychotherapy and rationales including a plan for follow-up parameters and referrals(Comprehensive Psychiatric Evaluation Note and Patient Case Presentation Essay)
20 to >17.0 pts
Excellent
The video clearly and concisely outlines an evidence-based treatment plan for the patient that addresses treatment modality, psychotherapy choice with framework principles, and rationale. … Discussion includes a clear and concise follow-up plan and parameters…. The discussion includes a clear and concise referral plan.(Comprehensive Psychiatric Evaluation Note and Patient Case Presentation Essay)
17 to >15.0 pts
Good
The video clearly outlines an appropriate treatment plan without evidence-based discussion for the patient that addresses treatment modality, psychotherapy choice with framework principles, and rationale. … Discussion includes a clear follow-up plan and parameters…. The discussion includes a clear referral plan.(Comprehensive Psychiatric Evaluation Note and Patient Case Presentation Essay)
15 to >13.0 pts
Fair
The response somewhat vaguely or inaccurately outlines a treatment plan for the patient and provides a rationale for the treatment approaches recommended…. The discussion is somewhat vague or inaccurate regarding the follow-up plan and parameters…. The discussion is somewhat vague or inaccurate regarding a referral plan.(Comprehensive Psychiatric Evaluation Note and Patient Case Presentation Essay)
13 to >0 pts
Poor
The response does not address the treatment plan or the treatment plan is not appropriate for the assessment and the diagnosis or is missing elements of the treatment plan. … There is no discussion for follow-up and parameters. … There is no discussion of a referral plan.(Comprehensive Psychiatric Evaluation Note and Patient Case Presentation Essay)
20 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 >3.5 pts
Good
Presentation style is clear, professional, and focused.
3.5 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
Comprehensive Psychiatric Evaluation Note and Patient Case Presentation Essay
Subjective:
CC (chief complaint): “I am overweight, I cannot stop eating, and no one loves me.”
HPI: JD is a 14-year-old female of African American descent who presents for a psychiatric evaluation in an inpatient crisis unit following a referral by her school nurse. The client complains of being overweight and cannot stop eating. She says that nobody loves her. Before referral by the school nurse, she had intentionally cut herself at home. As a result, she could not participate in her class due to too much bleeding from the cuts. The client has previously written suicide statements before entering the crisis unit.(Comprehensive Psychiatric Evaluation Note and Patient Case Presentation Essay) She reports engaging in non-suicidal self-injury behavior as she feels hopeless, cannot stop eating, or pass her math test. She used a disposable razor to cut herself. The self-cutting behavior started six months ago. She has a problem with binge eating and sometimes tries to restrict her food intake. She experiences low self-esteem and fatigue. She reports conflict with her mother and family members, the pressure they put on her to get good grades and get into a good college, and the pressure she puts on herself to finish her school week. She used to participate in the school band but stopped as she no longer has an interest. The client’s mother is frustrated and has difficulty understanding why the client disrespects her considering she gives her everything she wants. Her mom is very strict and has taken her phone away. She expects the patient to act respectfully since she works and does not have time to spend with the client.(Comprehensive Psychiatric Evaluation Note and Patient Case Presentation Essay)
Past Psychiatric History: No past psychiatric history.
General Statement: This is the first time the client is entering treatment for psychiatric evaluation.
Caregivers (if applicable): Her mother and grandmother are her caregivers.
Hospitalizations: No history of hospitalization or surgery.
Medication trials: Denies medication trials.
Substance Current Use and History: Denies drug or alcohol abuse.
Family Psychiatric/Substance Use History: Denies family history of mental health illness or substance use diagnosis.
Psychosocial History: The client was born full-time. She lives with her mother and maternal grandmother. The parents never got married. The client has a problematic relationship with the mother. She just started high school. The client has no history of trauma or abuse.(Comprehensive Psychiatric Evaluation Note and Patient Case Presentation Essay)
Medical History: Asthma(Comprehensive Psychiatric Evaluation Note and Patient Case Presentation Essay)
Current Medications: None reported.
Allergies: No known drug allergies
Reproductive Hx: Not sexually active.(Comprehensive Psychiatric Evaluation Note and Patient Case Presentation Essay)
ROS:
HEENT: No headache/injury/trauma. No visual changes. No hearing loss. No sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain or discomfort. No dyspnea, palpitation, orthopnea, or paroxysmal, or oedema.
RESPIRATORY: Clear lung sounds
GASTROINTESTINAL: No nausea, vomiting, or diarrhea. No abdominal pain or constipation.
GENITOURINARY: Normal bladder and bowel functions. No burning or urinary urgency. No hematuria.
NEUROLOGICAL: No numbness, slurred speech, or ataxia.
HEMATOLOGIC: No easy bruising or bleeding.(Comprehensive Psychiatric Evaluation Note and Patient Case Presentation Essay)
LYMPHATICS: No painful or swollen lymph nodes.
ENDOCRINOLOGIC: No polyuria or polydipsia. Reports polyphagia.
Objective:
Physical Exams: Completed by the school nurse.
Diagnostic results: For this case, the beck depression inventory (BDI) would be ideal in providing additional data based on the DSM-5 to aid definitive diagnosis. The BDI is effective for evaluating the behavioral symptoms and severity of depression (Hubley, 2021). Besides, it is reliable and sensitive to behavioral manifestations of depression (Lee & Park, 2022). The BDI is recommended for ages 13 to 80 years, thus, relevant for this case.(Comprehensive Psychiatric Evaluation Note and Patient Case Presentation Essay)
Assessment:
Mental Status Examination: JD is a 14-year-old female referred to the facility by the school nurse for psychiatric evaluation. JD is well-dressed and looks her stated age. She is alert, oriented to place and person, and cooperative during the exam. She appears distressed and restless and does not make appropriate eye contact. JD fidgets throughout the examination. However, she can retain detailed information. Her judgment is below average. Denies any auditory and visual hallucinations. The client’s thought process is slow yet coherent and goal-directed. Thought content suggests distress about peer pressure. The client’s mood is down and congruent with the constricted affect. The client denies suicide ideation or plan. However, the client reported a suicide statement before entering treatment. The client recently cut herself using a razor blade and could not be in class as she was bleeding. The client is currently assessed to be at risk for self-harm.(Comprehensive Psychiatric Evaluation Note and Patient Case Presentation Essay)
Differential Diagnoses
- Major Depressive Disorder, 296.23 (F32.2). The client resents symptoms that meet the diagnostic criteria for severe major depressive disorders (MDD) with melancholic features. For a diagnosis to be made, a client must present five or more of the MDD symptoms in two weeks (American Psychiatric Association [APA], 2019). These symptoms include subjective or observed depressed mood or market diminished pleasures in almost every pleasurable activity, significant weight loss or gain, decrease or increase in appetite, insomnia/hypersomnia, psychomotor retardation or agitation, low energy, worthlessness, inability to concentrate or maintain attention, and recurrent thought of death. These symptoms are associated with significant distress and impairment in various areas of function.(Comprehensive Psychiatric Evaluation Note and Patient Case Presentation Essay)
- Borderline personality disorder, 301.83 (F60.3). The client presents symptoms that suggest borderline personality disorder (BPD). BPD is a persistent instability pattern associated with self-image, relationships, and affects. Affected individuals experience frantic efforts towards real or imagined abandonment, unstable relationships, impulsivity in functioning, market, and persistent negative self-image or sense of self (APA, 2019). Recurrent suicidal behavior, instability, feelings of emptiness, anger/difficulty controlling anger, and paranoia/dissociative symptoms. Symptoms usually present in early adulthood and can be shown in different contexts. BPD reactions are extreme, inappropriate, and disproportional, leading to a distorted sense of self and altered identity. This is a secondary diagnosis.(Comprehensive Psychiatric Evaluation Note and Patient Case Presentation Essay)
- Adjustment disorder, 309.0 (F43.21). The client’s symptoms also suggest adjustment disorder (AD) with a depressed mood. For an individual to be diagnosed with AD, they must present behavioral/emotional symptoms associated with a known stressor that causes significant distress and impairment in significant areas of functioning. These symptoms must occur in three months and are clinically significant (APA, 2019). AD with depressed mood has symptoms such as tearfulness, low mood, and hopelessness (APA, 2019). This diagnosis is refuted.(Comprehensive Psychiatric Evaluation Note and Patient Case Presentation Essay)
- Reflection
The client is a 14-year-old female who reports low self-esteem and argues that she is worthless and unloved. The client’s symptoms meet the full diagnostic criteria for MDD diagnosis. Therefore, MDD is the primary diagnosis. The risk and prognostic factors for MDD are broad and could include temperamental, environmental, and genetic/physiological. Individuals with negative affectivity are more likely to develop MDD from stressful events (Boland et al., 2021).
On the other hand, adverse childhood experiences are known risk factors for developing MDD (Boland et al., 2021). Lastly, Studies have shown that individuals whose first-degree relatives had been diagnosed with MDD are likely to be diagnosed with the same condition since MDD heritability is about 40%. Other factors, including mental illnesses such as anxiety, borderline personality disorder, and substance use disorders, are course modifiers for the development of MDD.
BPD is often diagnosed in early adults, i.e., from 18 to 30 years. This argument is because personalities are still developing in children and teenagers. However, studies have shown that BPD can be diagnosed as early as adolescents with persistent symptoms (Hessels et al., 2022). Negative interactions with parents, particularly mothers, have been associated with early diagnosis of BPD. In this case, the relationship between the client and the mother is negative, whereby the mother blames the client for being respectful, while the client blames the mother for pressuring her and being strict. The relationship is negative and leads, which leads the client to devalue herself. Impulsivity is observed in the client’s self-damaging behavior, i.e., cutting herself with a razor blade and binge eating. The client feels worthless and has dysphoria. However, this diagnosis is refuted since there are no observed or subjective reports of frantic efforts to avoid imagined or real abandonment. Moreover, there client’s present psychiatric history does not indicate a pervasive pattern of self-image.(Comprehensive Psychiatric Evaluation Note and Patient Case Presentation Essay)
AD with depressed mood is only diagnosed when it occurs in response to a psychological stressor, and the full criteria for MDD have not been met. In this case, the client’s source of stress could be school, for she just started school, and there is no history of similar symptoms before them. However, the client’s symptoms meet the full criteria for MDD diagnosis. Therefore, AD is refuted. As the primary diagnosis, cultural-related issues affect MDD presentation and diagnosis. MDD varies across cultures yet is consistent in the female-to-male ratio. However, there is no simple cultural linkage to MDD, but mental health expert needs to be wary of somatic symptoms in a primary care setting in cultures where MDD go unrecognized (APA, 2019). The higher prevalence is common in females compared to males, with no apparent gender-specific differences in treatment, consequences, and symptoms (APA, 2019). Besides, risks of suicide are higher in females, yet lower completion rates. Therefore, suicide risk assessment is crucial when dealing with adolescents presenting MDD symptoms.(Comprehensive Psychiatric Evaluation Note and Patient Case Presentation Essay)
Case Formulation and Treatment Plan(Comprehensive Psychiatric Evaluation Note and Patient Case Presentation Essay)
Start Fluoxetine 10mg PO QD in the morning. Fluoxetine is recommended for persons aged 8 to 18 years. Fluoxetine is effective and has been shown to relieve depressive symptoms and prevent relapse among individuals diagnosed with major depressive disorder.(Comprehensive Psychiatric Evaluation Note and Patient Case Presentation Essay)
Refer to a therapist for Dialectical behavior therapy (DBT). DBT is a talk therapy base on cognitive behavioral therapy adapted for individuals who experience intense emotions (Saito et al., 2020). This intervention will help the client understand and accept her feelings and learn skills to manage them. Studies have shown that DBT is effective as a long-term behavioral intervention therapy for groups and individuals experiencing emotional issues (Boland et al., 2021). Besides, the DBT will help the client manage suicidal thoughts and behaviors. Mindfulness training is the central concept adopted in DBT to achieve self-acceptance, avoid self-destructive behavior, and tolerate distress.
Educate the client’s mother on the available resources, such as the Balanced Mind Parent Network, which provides information to parents raining children having mood disorders. The client and the parent are instructed to dial 911 or go to the nearest ER in the vent of active suicide ideation.
The client is to return to the facility after two weeks.(Comprehensive Psychiatric Evaluation Note and Patient Case Presentation Essay)
References - American Psychiatric Association. (2019). Diagnostic and statistical manual of mental disorders (7th ed.). American Psychiatric Publishing, Inc. (Comprehensive Psychiatric Evaluation Note and Patient Case Presentation Essay)
Hessels, C. J., van den Berg, T., Lucassen, S. A., Laceulle, O. M., & van Aken, M. A. (2022). Borderline personality disorder in young people: associations with support and negative interactions in relationships with mothers and a best friend. Borderline Personality Disorder and Emotion Dysregulation, 9(1), 1-11. https://doi.org/10.1186/s40479-021-00173-7
Hubley, A. M. (2021). Beck depression inventory. In Encyclopedia of Quality of Life and Well-Being Research (pp. 1-11). Cham: Springer International Publishing. Available at: https://link.springer.com/referenceworkentry/10.1007/978-3-319-69909-7_156-2 (Accessed 6 December 2022)(Comprehensive Psychiatric Evaluation Note and Patient Case Presentation Essay)
Lee, A., & Park, J. (2022). Diagnostic test accuracy of the beck depression inventory for detecting major depression in adolescents: A systematic review and meta-analysis. Clinical Nursing Research, 31(8), 1481-1490. https://doi.org/10.1177/10547738211065105(Comprehensive Psychiatric Evaluation Note and Patient Case Presentation Essay)
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