PRAC 6645 Comprehensive Psychiatric Evaluation and Patient Case Presentation, Part 1

PRAC 6645 Comprehensive Psychiatric Evaluation and Patient Case Presentation, Part 1

Subjective:

Chief Complaint: The client’s mother reported, “My child is behaving abnormally. He violates the rights of others and bullies his peers. He is getting out of control.”

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History of Present Illness: A.A is a 13-year-old client referred for psychiatric assessment due to concerning behavior. The client’s mother reported that for the past six months, A.A has exhibited aggressive and disruptive behaviors. These behaviors include bullying peers, making threats, frequent involvement in fights, and even physically harming a friend with a stick during a disagreement. Recently, A.A was accused of stealing a book at school. The mother attempted talking to and seeking counseling for A.A, but without success. She expressed growing concern about the escalating frequency of these behaviors, leading to their referral for psychiatric assessment.

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Past Psychiatric History:

– Caregivers: A.A’s mother.
– Hospitalizations: No history of hospitalizations.
– Medication Trials: No history of medication use.
– Psychotherapy or Previous Psychiatric Diagnosis: Previous attempts at counseling were not effective.

Substance Use and History: A.A denied any history of substance abuse.

Family Psychiatric/Substance Use History: The mother reported her father’s history of depression and her husband’s father living with Alzheimer’s disease. There was no history of drugs or substance abuse in the family.

Psychosocial History: A.A is the eldest of three siblings, living with his parents in a healthy environment. He is a junior high school student with hobbies that include playing with peers and watching television. He has no history of childhood trauma, violence, or involvement with the legal system.

Medical History:

– Current Medications: A.A is not currently on any medications.
– Allergies: No history of food, drug, or environmental allergies.
– Reproductive History: A.A denied any issues related to urinary urgency and frequency, and he is not sexually active.

Objective:

Diagnostic Results: The diagnosis for A.A primarily relies on a comprehensive assessment, combining physical examination and history taking. These assessments aim to rule out conduct disorder or other medical conditions. Laboratory investigations, such as blood tests, may be conducted to assess for abnormal biomarkers or electrolyte imbalances. Thyroid function tests could be performed to rule out thyroid disorders, which may present with similar symptoms. In rare cases, neuroimaging, like brain scans, might be considered to explore potential brain pathologies affecting behavior.

Assessment:

Mental Status Examination: A.A, a 13-year-old, presented as appropriately dressed without signs of fatigue or abnormal movements. He displayed orientation to place, time, events, and space. His insight was intact, with an absence of a depressed mood. A.A denied experiencing illusions, delusions, hallucinations, suicidal thoughts, attempts, or plans. His thought content was future-oriented, and he exhibited normal speech in terms of rate and volume.

Differential Diagnoses:

1. Conduct Disorder: A.A’s primary diagnosis is conduct disorder, in accordance with the DSM-V criteria. He exhibits a pattern of disruptive and impulsive behaviors that violate societal norms and the rights of others, lasting for over 12 months. The behaviors include bullying, physical fights, using weapons, cruelty to people and animals, stealing, forced sexual activity, property destruction, arson, and other disruptive actions.

2. Attention Deficit Hyperactivity Disorder (ADHD): ADHD is a secondary diagnosis to consider due to the presence of symptoms related to inattention and hyperactivity or impulsivity. However, given A.A’s predominantly disruptive behaviors, ADHD is less likely.

3. Oppositional Defiant Disorder: Another secondary diagnosis is oppositional defiant disorder, characterized by irritable mood, argumentative behavior, and vindictiveness. However, this is less likely as A.A’s behaviors extend beyond defiance and involve harmful actions.

Reflections: Conduct disorder is a common issue in children and adolescents, characterized by behaviors that contravene societal norms and infringe on the rights of others. The diagnosis is appropriate, and cognitive-behavioral therapy is a suitable treatment approach. The importance of comprehensive examination and involving significant others in the history-taking process is evident. In the future, incorporating family therapy could enhance family dynamics.

Case Formulation and Treatment Plan: A.A’s diagnosis of conduct disorder was made based on subjective information. Diagnostic investigations were not conducted due to the reliability of the reported data. Treatment will begin with behavior modification therapy to address impulsive and intrusive symptoms. A follow-up visit is scheduled after four weeks to evaluate treatment response.

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.

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.
• 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 of each page that is initialed and signed by your Preceptor.

SUBMISSION INFORMATION – PART 1: RECORDING

SUBMISSION INFORMATION – PART 2: COMPREHENSIVE PSYCHIATRIC EVALUATION NOTE