Assignment 2: Comprehensive Psychiatric Evaluation and Patient Case Presentation

Assignment 2: Comprehensive Psychiatric Evaluation and Patient Case PresentationComprehensive psychiatric evaluations are a way to reflect on your practicum experiences and connect the experiences to the learning you gain from your weekly Learning Resources. Comprehensive 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 during the last 3 weeks, using the Comprehensive Psychiatric Evaluation 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. Also review the Kaltura Media Uploader resource in the left-hand navigation of the classroom for help creating your self-recorded Kaltura video.
• Select a patient that you examined during the last 3 weeks who presented with a disorder other than a mood disorder.
• Conduct a Comprehensive Psychiatric Evaluation on this patient using the template provided in the Learning Resources. There is also a completed exemplar document in the Learning Resources so that you can see an example of the types of information a completed evaluation document should contain. All psychiatric evaluations must be signed, and each page must be initialed by your Preceptor. When you submit your document, you should include the complete Comprehensive Psychiatric Evaluation as a Word document, as well as a PDF/images of each page that is initialed and signed by your Preceptor. You must submit your document 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 Late Policies.
• Develop a video case presentation, based on your evaluation of this patient, that includes chief complaint; history of present illness; any pertinent past psychiatric, substance use, medical, social, family history; most recent mental status exam; and current psychiatric diagnosis, including differentials that were ruled out.
• Include at least five (5) scholarly resources to support your assessment and diagnostic reasoning.
• Ensure that you have the appropriate lighting and equipment to record the presentation.Assignment
Record yourself presenting the complex case 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 case. Include chief complaint; history of present illness; any pertinent past psychiatric, substance use, medical, social, family history; most recent mental status exam; and current psychiatric diagnosis including differentials that were ruled out.
• Report normal diagnostic results as the name of the test and “normal” (rather than specific value). Abnormal results should be reported as a specific value.
Be succinct in your presentation, and do not exceed 8 minutes. Address the following:
• Subjective: What details did the patient provide regarding their personal and medical history? What are their symptoms of concern? How long have they been experiencing them, and what is the severity? How are their symptoms impacting their functioning?
• Objective: What observations did you make during the interview and review of systems?
• Assessment: What were your differential diagnoses? Provide a minimum of three (3) possible diagnoses. List them from highest to lowest priority. What was your primary diagnosis and why?
• Reflection notes: What would you do differently in a similar patient evaluation?51-year old Hispanic Spanish male present with an interpreter. The patient is alert and oriented x4 with minimal eye contact attitude is cooperative, mood is depressed, thought content is normal, the patient denies hallucinations, denies suicidal/homicidal, and insight judgement is intact. The patient starts crying “I am depressed, I can’t sleep. I feel embarrassed about myself and my situation. I just want to sit in the sun, and I don’t want to do anything. I have no energy. I don’t have the strength to do things with my family. I have pain in my back and arm. I cry a lot. I am nervous, I have to drive I have severe anxiety. I don’t let my wife drive because I was hit by a car by a woman and I fear that will happen if my wife drives. I get very angry. I am easily irritable and stressed out. I haven’t seen my family because of COVID and if feel incompetent I can’t help my wife with the duties at home and kids.”The patient “Tom” to use Mood was depressed, anxious. Facial expression was constricted, tense and sad. Displayed facial grimaces suggesting that he was in pain, which was interfering with his mental focus and attending to posted inquires was openly crying relating his suffering and mental distress. His thought content appeared to be normal. Denies having any visual, auditory, olfactory, and tactile hallucinations. Alert and oriented to time, place, person, and purpose. His immediate memory was good. His judgement was assessed to be good, and his insight appeared to be good. The patient showed a lack of thought or intelligence. The patient was assessed to be good, and his insight appeared to be good. There are problems with attentiveness. The patient does suffer from indecisiveness. Stress: stressors were work, illness. Coping ability was overwhelmed that disrupted activities of daily living.Test administered: Hamilton Rating Scale for Anxiety (HAM-A)
Hamilton Rating Scale for depression (HAM-D) Beck Depression Inventory (BDI)Diagnosis Major Depressive Disorder single episode, SevereThe patient indicates at this time specifically to continue treatment with current psychiatrist
Medication options psychiatric intervention is indicated at this time specifically “Tom” should continue treatment with the use of psychotropic: Antidepressant, anxiety, insomnia, and psychosis.Bupropion XL 150mg in the morning for depression
Buspar 10mg twice a day for anxiety
Trazadone 50 mg, before sleep as needed for depression and insomnia.Therapy options Psychological consultation is also advisable group or individual psychotherapy for depression, anxiety, and insomniaPast medical History The patient has blood pressure, is prediabetic and has high cholesterol.
Past work-related injuries: the patient history for past work-related injuries is unremarkable.Past automobile sport or personal injuries: The patient’s history for past automobile and sport injuries is unremarkable.Medications: The patient is currently taking medications for high blood pressure, high cholesterol, and for blood clotsAllergies: The patient reports no known allergies.Social History: The patient stated he is married. He does have children,4 of them. Patient states he does not drink alcohol. Patient states he does not use tobacco. Patient state he does not use drugs prescription or street drugs.Review of Systems: The patient denies any recent exposure to anyone at risk or infected with COVID 19 virus. The patient denies having any symptoms of fever, sore throat, shortness of breath, cough, any loss of smell or taste or diarrhea at the present time.Pulmonary: The patient denies cough. The patient denies asthma. The patient denies wheezing. The patient denies hemoptysis. The patient denies shortness of breath. The patient denies dyspnea on exertion. The patient denies bronchitis. The patient denies history of tuberculosis.
Cardiac: The patient denies history of chest pain. The patient denies syncope. The patient denies malignant arrythmias. The patient denies heart attack. The patient denies murmur.
Gastrointestinal: The patient denies gastroesophageal reflux disease. The patient denies irritable bowel syndrome. The patient denies abdominal pain. The patient denies melena. The patient denies rectal bleeding. The patient denies peptic ulcer disease. The patient denies hepatitis.
Genitourinary: The patient denies hesitancy. The patient denies urgency. The patient denies frequency. The patient denies history of renal stones. The patient denies incontinence.
Sexual Dysfunction: The patient denies sexual dysfunction. The patient denies loss of libido. The patient denies pain during intercourse.Physical Examination
Vital signs:
Height: 5’6”
Weight: 344
Temperature: 97.2 F
Blood pressure: 144/74
Pulse: 82
Oxygen: 98
History of injury:
“Tom” is a Spanish speaking patient who reports having been involved in a specific injury during his usual and customary work duties as a concrete finisher. On 01/2020 head, teeth, neck, back, right shoulder, right wrist, right hand, right hip, right knee, right ankle and right foot. The patient also developed anxiety, depression, aggravation to high blood pressure, became pre diabetic, experienced weight gain approximately 25 pounds and hearing loss. History of bipolar. When “Tom” was working on the street on 01/14/2020 he was struck by a motor vehicle on his right calf causing the patient to land backwards on his head. He states he was transported by ambulance to the nearest hospital where he was evaluated, and diagnostic studies were taken. The patient was advised he had fractured his right wrist and underwent surgery to apply a metal plate on 01/15/2020. The patient states his right leg became swollen after the 01/15/2020 surgery and he was given medication for blood clots. The patient states he has received medical treatment and physical therapy and is awaiting a consultation by an internist. He states at the moment he is currently working and has not worked since the day of his injury.Job Description: A concrete finisher setting forms and applying concrete.Diagnosis:Headache
Cervicalgia
Sprain of other parts of thorax, initial encounter
Low back pain
Adhesive capsulitis of right shoulder
Carpal tunnel syndrome, right upper limb
Unspecified sprain of right hip, initial encounter
Sprain of unspecified site of right knee, initial encounter
Sprain of unspecified ligament of right ankle, initial encounter
Pain in right foot
Essential (primary) hypertension
Type 2 diabetes mellitus without complications
Tinnitus, bilateral
Sleep related bruxism
Insomnia due to medical condition
Obstructive sleep apnea
Anxiety disorder, unspecified
Abnormal weight gain
Obesity, unspecifiedTreatment/Therapy Recommendations:
Patient is unable to return to work as a result of the symptoms suffered from the work-related injury on 01/14/2020. The patient complains of discomfort of the ears. The patient reports loss of hearing on the right ear with occasional ringing. Patient will require an evaluation with an ENT physician. The patient states that currently, because of his intense pain, his activities of daily living remain greatly impaired. Moreover, he continues to have sleep difficulty which, in turn has caused a psychological/emotional reaction, including frustration, depression, irritability and high anxiety in response to his pain and limitations. The patient has been somewhat sedentary since the 01/14/2020 injury. The patient has indicated that he has gained approximately 25 pounds since 01/14/2020. There are sleep complaints. Patient complains of snoring and loss of sleep. Patient indicates that he occasionally stops breathing at times when he is sleeping which causes him to wake up at night. The patient has been recommended a psychiatric evaluation. The patient complains of jaw pain. The patient reports chipping one of his front tooth as a result of the 01/14/2020 accident. Referral to a dentist. A sleep study and treatment with a CPAP due to the chance of mortality due to untreated sleep apnea. Untreated sleep apnea will also complicate the patient’s medical condition. Manage DVT and anticoagulationAll references require creditable sources, nothing less than 5 years. References require APA 7th edition http. Please add conclusion. would want to make treatment recommendations for anxiety and include a support component.——
– Sample AnswerStudent’s Name
Institutional Affiliation
Course
Professor’s Name
DateNRNP/PRAC 6635 Comprehensive Psychiatric Evaluation
CC (chief complaint): I am depressed, I can’t sleep. I feel embarrassed about myself and my situation. I just want to sit in the sun, and I don’t want to do anything. I have no energy. I don’t have the strength to do things with my family. I have pain in my back and arm. I cry a lot. I am nervous, I have to drive I don’t let my wife drive because I was hit by a car by a woman and I fear that will happen if my wife drives. I get very angry. I am easily irritable and stressed out. I haven’t seen my family because of COVID and if feel incompetent I can’t help my wife with the duties at home and kids.
HPI: 51-year old Hispanic Spanish male present with an interpreter. The patient is alert and oriented x4 with minimal eye contact attitude is cooperative, the mood is depressed, thought content is normal, the patient denies hallucinations, denies suicidal/homicidal, and insight judgment is intact. The patient complains that he is depressed and cannot sleep.
Past Psychiatric History:
· General Statement: The patient’s psychiatric history is unremarkable.
· Caregivers (if applicable): The patient has no caregiver.
· Hospitalizations: The patient’s history of hospitalization is unremarkable.
· Medication trials: The patient has no medications for a psychiatric condition.
· Psychotherapy or Previous Psychiatric Diagnosis: The patient has no history of psychotherapy for any mental condition.
Substance Current Use and History: The patient’s history of substance use is unremarkable.
Family Psychiatric/Substance Use History: The patient stated he is married. He does have children,4 of them. The patient states he does not drink alcohol. The patient states he does not use tobacco. The patient state he does not use drugs prescription or street drugs.Psychosocial History: The patient stated he is married. He does have children,4 of them. He does customary work duties as a concrete finisher especially setting forms and applying concrete.
Medical History: The patient is currently taking medications for high blood pressure, high cholesterol, and blood clots.
· Current Medications: The patient is currently taking medications for high blood pressure, high cholesterol, and blood clots
· Allergies: The patient reports no known allergies.
• Reproductive Hx: The patient is married, sexually active, and has no complications such as pain during intercourse.
ROS:
· GENERAL: Patient complains of depression and irregular sleep patterns.
· HEENT: No blurred vision, hearing difficulties, nasal congestion, or sore throat.
· SKIN: No itching or rashes.
· CARDIOVASCULAR: No edema or chest pressure.
· RESPIRATORY: No respiratory challenges or congestion.
· GASTROINTESTINAL: No nausea, vomiting, or diarrhea.
· GENITOURINARY: No polyuria or pain passing urine.
· NEUROLOGICAL: Normal bowel movement and passing urine.
· MUSCULOSKELETAL: No abnormalities or back pain.
· HEMATOLOGIC: No blood disorder.
· LYMPHATICS: No swollen lymph nodes.
· ENDOCRINOLOGIC: No excessive sweat or thirst.
Physical exam:
Vital signs: Height: 5’6”, Weight: 344, Temperature: 97.2 F, Blood pressure: 144/74, Pulse: 82, Oxygen: 98.
Diagnostic results:
Assessment
Mental Status Examination:
Hamilton Rating Scale for Depression (HAM-D) and the Beck Depression Inventory (BDI)
Diagnostic results: Major Depressive Disorder single episode, severe
Differential Diagnoses:
Major Depressive Disorder (MDD)
MDD is a mental condition that leads to depressed mood and loss of interest in daily activities. The effects of MDD affects the quality of life. Some of the symptoms include changes in sleep patterns, body weakness, lack of concentration, and poor self-esteem (Kohler‐Forsberg et al., 2019). MDD can trigger suicidal thoughts. In some cases, patients experience unintentional weight gain or weight loss. Hamilton Rating Scale for Depression (HAM-D) and the Beck Depression Inventory (BDI) are important in the diagnostic process (Kohler‐Forsberg et al., 2019). The treatment of MDD requires medication or talk therapy or a combination of the two. Studies show that a combination of pharmacological and non-pharmacological approaches is crucial in generating positive results (Belujon & Grace, 2017). Statistics show that over 17.3 million have at least one major depressive disorder representing 7.1 percent. The prevalence of MDD is higher among females at 8.7 percent compared to males at 5.3 percent (Kohler‐Forsberg et al., 2019). While MDD can develop at any age, the median age is 32.5 years.
Dementia
Dementia a mental condition that leads to loss of memory, thinking, problem-solving, and language capabilities. The thinking and social symptoms interfere with the quality of life (Clarkson et al., 2017). Treatment procedures focus on limiting the severity of the symptoms since there is no cure for dementia. Rehabilitation and occupational therapy are one of the approaches that can address the condition (Clarkson et al., 2017). The cause of dementia is the damage of brain cells leading to poor communication among the cells. Over 5.8 million Americans have dementia with 80 percent being 75 years or older
Borderline personality disorder (BPD)
BPD is also known as an emotionally unstable personality disorder (EUPD) since it is a mental condition that affects relationships, sense of self, strong emotional reactions. The symptoms include emotional instability, low self-esteem, and poor social relationships (Cristea et al., 2017). The cause of BPD is not clear, but some researchers suggest that genetics, social, cultural, and environmental factors, and brain structure. Treatment involves psychotherapy but medication may be added to enhance the efficacy of the medication (Cristea et al., 2017). Surveys indicate that over 1.6 million Americans have the condition.
Bipolar disorder
Bipolar disorder is a mental condition that triggers extreme mood swings including depressive lows and manic highs. Research suggests that the cause of the disease is not clear, but some factors such as environment, brain structure, and genetics may play a major role (Carvalho et al., 2020). Treatment involves psychotherapy but medication may be added to enhance the efficacy of the medication (Carvalho et al., 2020). Statistics indicate 2.8 million Americans have bipolar disorder.
Obsessive-compulsive disorder (OCD)
OCD is a mental disease that leads to repetitive or obsessive thoughts or the need to perform some tasks repeatedly. The obsession and compulsion lead to distress and poor mental impairment (Hirschtritt et al., 2017). The symptoms begin gradually and vary from one patient to another. Some of the common symptoms include repetition of words, social isolation, fear of germs, nightmares, depression, anxiety, and panic attacks (Hirschtritt et al., 2017). Some major causes include genetic and hereditary factors. Statistics indicate that 2.2 million have OCD (Hirschtritt et al., 2017). Treatment of OCD involves a combination of therapy such as exposure and response prevention and medication.
Treatment:
Bupropion XL 150mg in the morning for depression.
Elavil 10mg, before sleep as needed for depression and insomnia.
Counseling sessions or talk therapy.
Reflections:
MDD is a mental condition that affects the quality of life of patients. Practitioners should use a combination of therapy and medication to enhance the quality of the outcomes. For example, the patient in the case study will need to take Bupropion XL 150mg and Bupropion XL 150mg to enhance the outcomes (Kohler‐Forsberg et al., 2019). I have learned that patients should be encouraged to adhere to the medication since nonadherence can trigger negative outcomes. While MDD affects the quality of life of patients, therapists should strive to diagnose and treat the conditions. I learned that although the cause is unknown, lifestyle changes are important in lessening the factors that trigger the condition. Some of the triggers include alcohol and drug use, hypothyroidism, steroids, and childhood abuse (Kohler‐Forsberg et al., 2019). The patients should avoid triggers since they can lead to adverse outcomes.References
Belujon, P., & Grace, A. A. (2017). Dopamine system dysregulation in major depressive disorders. International Journal of Neuropsychopharmacology, 20(12), 1036-1046. https://doi.org/10.1093/ijnp/pyx056
Carvalho, A. F., Firth, J., & Vieta, E. (2020). Bipolar disorder. New England Journal of Medicine, 383(1), 58-66. DOI: 10.1056/NEJMra1906193
Clarkson, P., Davies, L., Jasper, R., Loynes, N., Challis, D., in Dementia, H. S., & Group, P. M. (2017). A systematic review of the economic evidence for home support interventions in dementia. Value in Health, 20(8), 1198-1209. https://doi.org/10.1016/j.jval.2017.04.004
Cristea, I. A., Gentili, C., Cotet, C. D., Palomba, D., Barbui, C., & Cuijpers, P. (2017). Efficacy of psychotherapies for borderline personality disorder: a systematic review and meta-analysis. Jama psychiatry, 74(4), 319-328. doi:10.1001/jamapsychiatry.2016.4287
Hirschtritt, M. E., Bloch, M. H., & Mathews, C. A. (2017). Obsessive-compulsive disorder: advances in diagnosis and treatment. Jama, 317(13), 1358-1367. doi:10.1001/jama.2017.2200
Kohler‐Forsberg, O., N. Lydholm, C., Hjorthoj, C., Nordentoft, M., Mors, O., & Benros, M. E. (2019). Efficacy of anti‐inflammatory treatment on major depressive disorder or depressive symptoms: meta‐analysis of clinical trials. Acta Psychiatrica Scandinavica, 139(5), 404-419. https://doi.org/10.1111/acps.13016—–
Sample Answer 2
NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Exemplar
(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.)
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. This section contains the symptoms that is bringing the patient into your office. 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 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).
Assessment
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 diagnosis selection. 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!), 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
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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