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PRAC 6645 Week 7 Assignment 2: Comprehensive Psychiatric Evaluation Note and Patient Case Presentation PRAC 6645 Week 7 Assignment 2: Comprehensive Psychiatric Evaluation Note and Patient Case Presentation PRAC 6645 Week 7 Assignment 2: Comprehensive Psychiatric Evaluation Note and Patient Case Presentation Psychiatric notes are a way to reflect on your practicum experiences and connect the experiences to the learning you gain from your weekly Learning Resources. 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 at your practicum site, using the Comprehensive Psychiatric Evaluation Note 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 impulse-control and conduct disorders. Select a patient for whom you conducted psychotherapy for an impulse control or conduct disorder during the last 6 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 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 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 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 Media Uploader resource in the left-hand navigation of the classroom for help creating your self-recorded Kaltura video. 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 study 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 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 diagnostic criteria and is supported by the patient’s symptoms. Plan: What was your plan for psychotherapy (including one health promotion activity and one patient education strategy)? What was your plan for treatment and management, including alternative therapies? Include nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan. Reflection notes: What would you do differently with this patient if you could conduct the session again? By Day 7 Submit your Video and Comprehensive Psychiatric Evaluation Note Assignment. 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. Subjective: CC (chief complaint): School is requiring a psychiatric evaluation because patient was a “danger to herself”. HPI: C.F. is a 16-year-old Caucasian female who presented to this outpatient psychiatric center for further psychiatric evaluation required by school because she appeared to be a danger to herself. Patient reports suffering with depression and anxiety for years. However, it has gotten worst lately. Patient went to school on 09/28/2021 and reports she could not stop crying. She was evaluated by her school counselor/therapist who determined patient needed further psychiatric evaluation due to safety concern. Patient went to a different facility for psychiatric evaluation whom she felt was incompetent and therefore, decided to come here instead. Upon arrival to facility patient admitted to having current suicidal ideation (SI) with no plan or intent now. However, stated that due to her impulsive nature she could act on her SI. Nonetheless, patient reported she can keep herself safe for now because of the recent mental breakdown she had that usually leads to feeling content afterwards. Patient also reports she could talk to her parents if the thoughts got worse. Patient reports a history of 3 suicide attempts. Her first attempt was at age 7-8 y/o when she jumped off the roof her 2-story house after writing her will. The second attempt was in 8th grade and the third in freshman year. For either of the last two attempts patient does not recall the method, it was either by cutting herself or overdosing on pills. According to patient neither of the 3 suicide attempts caused any injury or required treatment. Patient denies any history of homicidal ideation (HI) or violence towards people/property. Patient does report history of self-injurious behavior (SIB) by cutting or scratching, which started in 6th grade. Most recent SIB was with fire a week prior to this admission. Patient reports she was messing around with fire but did not burn herself as she was able to distract herself. Patient reports being anxious all the time, which gets worse in social situations and school. Patient reports history of panic attacks during which patient has trouble breathing, body shuts down, cannot think, or speak. However, afterwards she either becomes non-responsiveness or aggressive. Patient reports her last panic attack was over the summer. Patient PRAC 6645 Week 7 Assignment 2 Comprehensive Psychiatric Evaluation Note and Patient Case Presentation reports experiencing a lot of online sexual harassment. Patient reports that she has been sexually involved in social media and has been groomed by older men (on the internet) over the years. Patient has this feeling of guilt and shame, and she blames herself for the actions of men on social media that have groomed her and sexually harassed her over the years. Patient reports she had been sexting and thinks her inappropriate pictures and videos are probably floating around on the internet. Reports being blackmailed to send more inappropriate pictures and videos with a threat to circulate her previously sent sextings. Patient denies reporting this to authorities. Patient reports constant racing and intrusive thoughts mostly sexual in nature. Patient reports having difficulty keeping friends because her thoughts about these friends often quickly turn sexual, which perhaps the friends catch and leave her. Patient reports distancing from family because her thoughts regarding family members could potentially and eventually automatically become sexual in nature. Academically patient has As and Bs in all classes except for Math which she is failing. However, patient reports no motivation left for school or work since she has been unfriended by all her friends even on social media. Reports difficulty falling and staying asleep, sleeps 5 hours with interruptions, wakes up several times. Patient also reports poor appetite, but denies restricting, binging, purging. Click here to ORDER an A++ paper from our Verified MASTERS and DOCTORATE WRITERS: PRAC 6645 Week 7 Assignment 2: Comprehensive Psychiatric Evaluation Note and Patient Case Presentation   Past Psychiatric History: General Statement: C.F. is a 16 y/o Caucasian female with h/o depression and anxiety since elementary age and relates most of it to her hypersexuality and actions such inappropriate use of social media, being groomed by men on social media over the years. Patient also has body image issues and difficulty maintaining friendships. Caregivers (if applicable): N/A. Hospitalizations: Denies Medication trials: Denies. However, family has had success with Zoloft and Lexapro. Family history of suicidality (genetic sensitivity) with Prozac. Psychotherapy or Previous Psychiatric Diagnosis: Sees a therapist once per week. Substance Current Use and History: History of occasional alcohol use. None currently. Family Psychiatric/Substance Use History: Not specific, but both parents suffer with depression and anxiety, Father has anger issues. Psychosocial History: Patient is a 16 y/o single female who lives at home with parents and 2 older sisters ages 18 (currently away for college) and 21-year-old patient is bisexual and reports interest in both boys and girls. She works as a receptionist at a local hair salon. Currently attending 11th grade at local high school. Not in any special program in school. Would like to be in a special program especially the ombudsmen program. Anxiety worsens in social situations and school. Medical History:   Current medical problems: Scoliosis (mild) Current Medications: None Allergies: No known food, drug, plant, animal, or medication allergies Reproductive Hx: Single, bisexual, regular periods ROS: GENERAL: Alert and oriented, groomed, appropriately dressed for the season and occasion. However, wearing dramatic eye make-up. Appears younger for age. HEENT: no issues SKIN: no issues CARDIOVASCULAR: no issues RESPIRATORY: no issues GASTROINTESTINAL: no issues GENITOURINARY: no issues NEUROLOGICAL: no issues MUSCULOSKELETAL: mild scoliosis, constant pain in both knees and back, wears corset for support. HEMATOLOGIC: no issues LYMPHATICS: no issues ENDOCRINOLOGIC: no issues Objective: Physical exam: Height – 151.1 cm (4’9”) Weight – 41.6 kg (91.7 lb) BMI – 19.8 Diagnostic results: N/A Assessment: Mental Status Examination: Appearance:  Client is well-kempt and appropriately dressed for age, weather, and occasion. Appears younger than stated age. Eye contact: Hesitant Speech: normal rhythm and volume Behavior: Cooperative, fidgety Psychomotor: Restless/fidgety Mood: depressed, anxious Affect: congruent with mood Thought Process: racing thoughts, but organized Thought Content:  No delusions, passive suicidal and self-harm ideation. No Homicidal ideation. Perception:  No reaction to external or internal stimuli. Attention/ Concentration: Able to concentrate and participate in the assessment as expected Cognition:  Alert, oriented X 4. Memory:  Short-term and long-term memory are grossly intact. Insight: limited Judgment: limited Fund of Knowledge:  Average. Intelligence:  Average. Differential Diagnoses: Major Depressive Disorder (severe) without psychosis The DSM V diagnostic criteria for MDD without psychosis include at least five of the following clinical features, with at least one of the features being a depressed mood or diminished interest in activities (Mullen, 2018). The five clinical features must have been present for at least two weeks (APA, 2013). The other symptoms include Appetite disturbance; Weight changes; Sleep disturbance; Fatigue or loss of energy; Psychomotor agitation or retardation; Feelings of guilt or worthlessness; A reduced ability to think or concentrate with indecisiveness; and recurrent thoughts of death or suicidal ideations without a specific plan, or a suicide attempt (APA, 2013). Pertinent symptoms supporting MDD as a differential diagnosis include the patient’s report of worsening depression with tearfulness, lack of motivation for school, sleep disturbances, and reduced appetite. In addition, the patient has feelings of guilt and shame about her actions. She engages in self-harm behavior and has suicidal ideations and a history of several suicide attempts, consistent with MDD. Generalized Anxiety Disorder (GAD) GAD manifests with excessive anxiety and worries about various events and activities. The anxiety and worry are usually difficult to control (APA, 2013). The anxiety and worry occur with at least three symptoms, which occur more days for at least six months. The accompanying symptoms include restlessness, easy fatigue, irritability, concentration difficulties, muscle tension, and sleep disturbance (APA, 2013). Suicidal ideation and attempts may occur with GAD. GAD is a differential diagnosis based on the client’s history of getting anxiety, which worsens in social situations and school and experiencing racing and intrusive thoughts. She also experiences sleep disturbances which are common in GAD. Panic attacks can be attributed to anxiety. Besides, she reports having suicidal ideations, which can occur in GAD. However, the patient’s symptoms do not fully meet the diagnostic criteria for GAD.   Bipolar II Disorder Bipolar disorder manifests with episodes of hypomania and major depression. Hypomanic episodes last about four days (Bobo, 2017). They are characterized by a mild elevated mood with an increased sense of psychological wellbeing and happiniess not associated with other events (APA, 2013). The hypomanic episodes also present with: An infkated self-esteem, reduced need for sleep, and over-involvement in pleasurable activities with painful consequences (APA, 2013). Pertinent positive findings supporting Bipolar II disorder depression symptoms, racing and intrusive thoughts, and engaging in pleasurable activities with adverse consequences, such as sending inappropriate pictures and videos on the internet. However, Bipolar II disorder is an unlikely diagnosis since the patient has no history of having episodes of elevated mood. Borderline Personality Disorder (BPD) BPD is characterized by an odd and eccentric personality. The diagnostic criteria include presence of: Unstable interpersonal relationships; Self-image problem; Trying too much to avoid being abandoned; Impulsive behavior; Recurrent self-mutilating behavior; Chronic feelings of emptiness; and entering into sexual liaisons (APA, 2013). BPD is a differential diagnosis based on the patient’s history of impulsivity, difficulties maintaining friends, recurrent self-mutilating behavior through cutting, burning, and suicide, and entering sexual liaisons through sexting and sending inappropriate behaviors Impulse Control Disorder (ICD) Persons with ICD typically present with a history of engaging in pleasurable or hedonic behaviors, such as gambling, shopping, or sex. The behaviors are conducted repetitively, excessively, or compulsively, to a level that interfere with major areas of life functioning (Fariba & Gokarakonda, 2021).  ICD manifest with a failure to resist an impulse, drive, or temptation to engage in an act that is harmful to the person or to others (Fariba & Gokarakonda, 2021). ICD is a differential diagnosis based on the patient’s report of engaging in hedonic behaviors such as sexting and sending inappropriate pictures and videos on the internet. However, it is an unlikely primary diagnosis since the patient does not experience the behavior as an impulse. Reflections: If I were to assess the patient again, I would utilize depression screening tools such as the Patient Health Questionnaire-9 (PHQ-9). The PHQ-9 would help assess the severity of the patient’s depression and confirm the differential diagnosis of MDD (Mullen, 2018). I would also use the Generalized Anxiety Disorder scale (GAD-7), a diagnostic self-report scale used to screen, diagnose, and assess the severity of anxiety disorders (Jordan et al., 2017). The screening tools would help in confirming or ruling out the differential diagnoses.   References American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub. Bobo, W. V. (2017, October). The diagnosis and management of bipolar I and II disorders: clinical practice update. In Mayo Clinic Proceedings (Vol. 92, No. 10, pp. 1532-1551). Elsevier. https://doi.org/10.1016/j.mayocp.2017.06.022 Fariba, K., & Gokarakonda, S. B. (2021). Impulse Control Disorders. StatPearls [Internet]. Jordan, P., Shedden-Mora, M. C., & Löwe, B. (2017). Psychometric analysis of the Generalized Anxiety Disorder scale (GAD-7) in primary care using modern item response theory. PloS one, 12(8), e0182162. https://doi.org/10.1371/journal.pone.0182162 Mullen, S. (2018). Major depressive disorder in children and adolescents. The mental health clinician, 8(6), 275–283. https://doi.org/10.9740/mhc.2018.11.275   Submission and Grading Information To submit your completed Assignment for review and grading, do the following: Please save your Assignment using the naming convention “WK7Assgn2+last name+first initial.(extension)” as the name. Click the Week 7 Assignment 2 Rubric to review the Grading Criteria for the Assignment. Click the Week 7 Assignment 2 link. You will also be able to “View Rubric” for grading criteria from this area. Next, from the Attach File area, click on the Browse My Computer button. Find the document you saved as “WK7Assgn2+last name+first initial.(extension)” and click Open. If applicable: From the Plagiarism Tools area, click the checkbox for I agree to submit my paper(s) to the Global Reference Database. Click on the Submit button to complete your submission. Grading Criteria To access your rubric: Week 7 Assignment 2 Rubric Check Your Assignment Draft for Authenticity To check your Assignment draft for authenticity: Submit your Week 7 Assignment 2 draft and review the originality report. Submit Your Assignment by Day 7 To participate in this Assignment: Week 7 Assignment 2 What’s Coming Up in Week 8? Photo Credit: [BrianAJackson]/[iStock / Getty Images Plus]/Getty Images Next week, you will continue your clinical hour and patient logs in Meditrek. You will also engage in reading selections to support your confidence in applying psychotherapy interventions for substance-related and addictive disorders. Next Week To go to the next week: Week 8 Name: PRAC_6645_Week7_Assignment2_Rubric Grid View List View Excellent Good Fair Poor Photo ID display and professional attire Points Range: 5 (5%) – 5 (5%) Photo ID is displayed. The student is dressed professionally. Points Range: 0 (0%) – 0 (0%) Points Range: 0 (0%) – 0 (0%) Points Range: 0 (0%) – 0 (0%) Photo ID is not displayed. Student must remedy this before grade is posted. The student is not dressed professionally. Time Points Range: 5 (5%) – 5 (5%) The video does not exceed the 8-minute time limit. Points Range: 0 (0%) – 0 (0%) Points Range: 0 (0%) – 0 (0%) Points Range: 0 (0%) – 3 (3%) The video exceeds the 8-minute time limit. (Note: Information presented after 8 minutes will not be evaluated for grade inclusion.) Discuss Subjective data: • Chief complaint • History of present illness (HPI) • Medications • Psychotherapy or previous psychiatric diagnosis • Pertinent histories and/or ROS Points Range: 9 (9%) – 10 (10%) 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. Points Range: 8 (8%) – 8 (8%) 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. Points Range: 7 (7%) – 7 (7%) 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. Points Range: 0 (0%) – 6 (6%) 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. 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 Points Range: 9 (9%) – 10 (10%) The video accurately and concisely documents the patient’s physical exam for pertinent systems. Pertinent diagnostic tests and their results are documented, as applicable. Points Range: 8 (8%) – 8 (8%) The response accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are documented, as applicable. Points Range: 7 (7%) – 7 (7%) Documentation of the patient’s physical exam is somewhat vague or contains minor inaccuracies. Diagnostic tests and their results are documented but contain inaccuracies. Points Range: 0 (0%) – 6 (6%) 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. 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. Points Range: 18 (18%) – 20 (20%) 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. Points Range: 16 (16%) – 17 (17%) 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. Points Range: 14 (14%) – 15 (15%) 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. Points Range: 0 (0%) – 13 (13%) 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. Discuss treatment Plan: • A treatment plan for the patient that addresses psychotherapy (including one health promotion activity and one patient education strategy); plan for treatment and management, including alternative therapies; nonpharmacologic treatments, alternative therapies, and follow-up parameters; and a rationale for the approaches selected. Points Range: 18 (18%) – 20 (20%) The video clearly and concisely outlines an evidence-based treatment plan for the patient that addresses psychotherapy, health promotion and patient education, treatment and management, nonpharmacologic treatments, alternative therapies, and follow-up parameters. A clear and concise rationale for the treatment approaches recommended is provided. Points Range: 16 (16%) – 17 (17%) The video clearly outlines an appropriate treatment plan for the patient that addresses psychotherapy, health promotion and patient education, treatment and management, nonpharmacologic treatments, alternative therapies, and follow-up parameters. A clear rationale for the treatment approaches recommended is provided. Points Range: 14 (14%) – 15 (15%) The response somewhat vaguely or inaccurately outlines a treatment plan for the patient and provides a rationale for the treatment approaches recommended. Points Range: 0 (0%) – 13 (13%) The response does not address the diagnosis or is missing elements of the treatment plan. Reflect on this case. Discuss what you learned and what you might do differently. Points Range: 5 (5%) – 5 (5%) Reflections are thorough, thoughtful, and demonstrate critical thinking. Points Range: 4 (4%) – 4 (4%) Reflections demonstrate critical thinking. Points Range: 3.5 (3.5%) – 3.5 (3.5%) Reflections are somewhat general or do not demonstrate critical thinking. Points Range: 0 (0%) – 3 (3%) Reflections are incomplete, inaccurate, or missing. Comprehensive Psychiatric Evaluation documentation Points Range: 18 (18%) – 20 (20%) The response clearly, accurately, and thoroughly follows the Comprehensive Psychiatric Evaluation format to document the selected patient case. Points Range: 16 (16%) – 17 (17%) The response accurately follows the Comprehensive Psychiatric Evaluation format to document the selected patient case. Points Range: 14 (14%) – 15 (15%) The response follows the Comprehensive Psychiatric Evaluation format to document the selected patient case, with some vagueness and inaccuracy. Points Range: 0 (0%) – 13 (13%) The response incompletely and inaccurately follows the Comprehensive Psychiatric Evaluation format to document the selected patient case. Presentation style Points Range: 5 (5%) – 5 (5%) Presentation style is exceptionally clear, professional, and focused. Points Range: 4 (4%) – 4 (4%) Presentation style is clear, professional, and focused. Points Range: 3.5 (3.5%) – 3.5 (3.5%) Presentation style is mostly clear, professional, and focused. Points Range: 0 (0%) – 2 (2%) Presentation style is unclear, unprofessional, and/or unfocused. Total Points: 100 Name: PRAC_6645_Week7_Assignment2_Rubric Order Now