Comprehensive Psychiatric Evaluation and Patient Case Presentation

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THESE PAPER WE ARE WRITING FOR ANY PATIENT WE HAVE TAKEN CARE OFI ATTACHED MY FRIENDS PAPER FOR AN EXAMPLE PLEASE 6635Assignment 2: Comprehensive Psychiatric Evaluation and Patient Case Presentation Comprehensive 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 2 weeks, using the Comprehensive Psychiatric Evaluation Template provided. You will then use this note to develop and record a case presentation for this patient. 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.Include at least five (5) scholarly resources to support your assessment and diagnostic reasoning.Ensure that you do not include any information that violates the principles of HIPAA (i.e., donâ€t use the patientâ€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.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? Rubric Detail Select Grid View or List View to change the rubric’s layout. Name: PRAC_6635_Week7_Assignment2_RubricGrid ViewList View ExcellentGoodFairPoorPhoto ID display and professional attire5 (5%) – 5 (5%)Photo ID is displayed. The student is dressed professionally.0 (0%) – 0 (0%)0 (0%) – 0 (0%)0 (0%) – 0 (0%)Photo ID is not displayed. Student must remedy this before grade is posted. The student is not dressed professionally.Time5 (5%) – 5 (5%)The video does not exceed the 8-minute time limit.0 (0%) – 0 (0%)0 (0%) – 0 (0%)0 (0%) – 0 (0%)The video exceeds the 8-minute time limit. (Note: Information presented after the 8 minutes will not be evaluated for grade inclusion.)Description of chief complaint and history of present illness5 (5%) – 5 (5%)The student provides an accurate, clear, and complete description of the chief complaint and history of present illness.4 (4%) – 4 (4%)The student provides an accurate description of the chief complaint and history of present illness.2 (2%) – 3 (3%)The student provides a vague, inaccurate, or incomplete description of the chief complaint and history of present illness, or description is missing.0 (0%) – 1 (1%)The student provides a completely inaccurate, or incomplete description of the chief complaint and history of present illness, or the description is missing.Description of past psychiatric, substance use, medical, social, and family history5 (5%) – 5 (5%)The student provides an accurate, clear, and complete description of past psychiatric, substance use, medical, social, and family history.4 (4%) – 4 (4%)The student provides an accurate description of past psychiatric, substance use, medical, social, and family history.2 (2%) – 3 (3%)The student provides a vague, inaccurate, or incomplete description of psychiatric, substance use, medical, social, and family history, or description is missing.0 (0%) – 1 (1%)The student provides a completely inaccurate, or incomplete description of psychiatric, substance use, medical, social, and family history, or description is missing.Discussion of most recent mental status exam and observations made during interview and review of systems14 (14%) – 15 (15%)The student provides an accurate, clear, and complete discussion of results from most recent mental status exam and observations made during interview and review of systems.12 (12%) – 13 (13%)The student provides an accurate discussion of results from most recent mental status exam and observations made during interview and review of systems.11 (11%) – 11 (11%)The student provides a vague, inaccurate, or incomplete discussion of results from most recent mental status exam and observations made during interview and review of systems.0 (0%) – 10 (10%)All or most of the discussion is inaccurate or missing.Discussion of diagnostics with results9 (9%) – 10 (10%)The student provides an accurate, clear, and complete discussion of diagnostics with results.8 (8%) – 8 (8%)The student provides an accurate discussion of diagnostics with results.7 (7%) – 7 (7%)The student provides a vague, inaccurate, or incomplete discussion of diagnostics with results.0 (0%) – 6 (6%)All or most of the discussion is inaccurate or missing.Diagnosis with three (3) differentials23 (23%) – 25 (25%)The student provides an accurate, clear, and complete diagnosis with three (3) differentials.20 (20%) – 22 (22%)The student provides an accurate diagnosis with three (3) differentials.18 (18%) – 19 (19%)The student provides a vague, inaccurate, less than 3 or incomplete diagnosis with differentials.0 (0%) – 17 (17%)All or most of the discussion is inaccurate or missing. Less than 2 diagnosis.Comprehensive Psychiatric Evaluation documentation23 (23%) – 25 (25%)The response clearly, accurately, and thoroughly follows the Comprehensive Psychiatric Evaluation format to document the selected patient case.20 (20%) – 22 (22%)The response accurately follows the Comprehensive Psychiatric Evaluation format to document the selected patient case.18 (18%) – 19 (19%)The response follows the Comprehensive Psychiatric Evaluation format to document the selected patient case, with some vagueness and inaccuracy.0 (0%) – 17 (17%)The response incompletely and inaccurately follows the Comprehensive Psychiatric Evaluation format to document the selected patient case.Presentation style5 (5%) – 5 (5%)Presentation style is exceptionally clear, professional, and focused.4 (4%) – 4 (4%)Presentation style is clear, professional, and focused.3 (3%) – 3 (3%)Presentation style is mostly clear, professional, and focused0 (0%) – 2 (2%)Presentation style is unclear, unprofessional, and/or unfocused. Total Points: 100Name: PRAC_6635_Week7_Assignment2_RubricAssessing and Diagnosing Patients with Schizophrenia, Other Psychotic Disorders, and Medication-Induced Movement Disorders THESE IS A PAPER FROM MY FRIEND LAST SEMISTAR U CAN USE IT AS AN AXMPLE PLEASE NamePMHNP, Walden UniversityNRNP 6635: Psychopathology and Diagnostic ReasoningDr. Keith Plowman01/16/2022          IntroductionThis weekâ€s case study involves a 19-year-old male who presents with psychotic symptoms. The patient, who has no past psychiatric treatment, presents with delusions, auditory hallucinations, and depressed mood. H had seen a councilor during his last year of high school due to stress and anxiety. He lives in a dorm five hours from home as he is a freshman at state college. The patient has become isolative in his dorm, coming out for meals and class only. His parents have become worried regarding his behaviors and made him an appointment for evaluation (Training video 29, 2016).The purpose of this paper is to conduct a comprehensive psychiatric evaluation within the provided case study. The information will include differential diagnosis based on the criteria of the American Psychiatric Association (APA) in the Diagnostic and Statistical Manual of Mental Disorders (5th ed.) (DSM-V). The paper will conclude with a reflection of the case, a discussion regarding prevention and management, and ethical considerations.NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation TemplateCC (chief complaint): “I guess I came in for brain check ups”HPI: The patient is a 19 -year-old Caucasian male who presents for a psychiatric evaluation for symptoms including anxiety, paranoia, and auditory hallucination at the request of his parents. He reports he does not know why he is being seen. The patient was suffering from stress and anxiety during the past year and once he moved away to college, he was reported to be isolative at school and has made few friends. He only leaves his dorm room to attend class or to eat. Past Psychiatric History: General Statement: The patient saw a counselor during his senior year in high school due to stress and anxiety.Caregivers (if applicable): Pt lives alone but his mother and father are involved in his treatmentHospitalizations: UnknownMedication trials: UnknownPsychotherapy or Previous Psychiatric Diagnosis: He has never had any psychiatric treatment in the past. Substance Current Use and History: He denies using any alcohol or drugs.Family Psychiatric/Substance Use History: He has a grandmother who was hospitalized in a psychiatric hospital multiple times for an unknown reason. Psychosocial History: The patient is a 19 -year-old Caucasian male. This is his first year of college He is a full-time student. He did well in high school taking advanced classes to go toward his college education. He lives in a college dorm with a roommate, five hours away his parents. He was raised by both parents, who are still married, and he is the first born of four children. He is currently not in a relationship. He works part-time in the computer lab. He runs track. He is on a college scholarship for track. Medical History: Pt with no medical issues. He had an appendectomy as a child.  Current Medications: Unable to assessAllergies: Unable to assessReproductive Hx: Unable to assessROS: GENERAL: Unable to assessHEENT: Unable to assessSKIN: Unable to assessCARDIOVASCULAR: Unable to assessRESPIRATORY: Unable to assessGASTROINTESTINAL: Unable to assessGENITOURINARY: Unable to assessNEUROLOGICAL: Unable to assessMUSCULOSKELETAL: Unable to assessHEMATOLOGIC: Unable to assessLYMPHATICS: Unable to assessENDOCRINOLOGIC: Unable to assessPhysical exam: Unable to assessDiagnostic results: AssessmentMental Status Examination: The patient is a 19-year-old Caucasian male who looks his stated age. He is dressed appropriately for the weather with good hygiene noted. He is slumped in his chair and fidgets with a jacket he has laid across his lap during the interview. He has poor eye contact. He is slow to respond to questions having a slightly angry attitude. Mood is depressed with a blunted affect. His speech is slow, monotone, with lower sound intensity. His thought process is irrational with abstractions, portraying ideas that differ from concrete reality. He denies knowing why he needs to see a psychiatrist. During the interview the patient displays delusional and paranoid thoughts including believing microwaves are killing people by either killing or draining blood cells from the body. He believes the interviewer will be safe from the microwaves as long as the patient is near. He talks of the room watching him and appears to be having auditory hallucinations as evidenced by silencing the interviewer to listen to an unknown source. He does not display any suicidal or homicidal thoughts. Cognitively, he is alert and oriented. Patient poor judgement and insight. Differential Diagnoses: Schizophrenia, paranoid type DSM-V Diagnostic Criteria:Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated). At least one of these must be (1), (2), or (3): Delusions. Hallucinations. Disorganized speech (e.g., frequent derailment or incoherence). Grossly disorganized or catatonic behavior. Negative symptoms (i.e., diminished emotional expression or avolition).(American Psychiatric Association. 2013).For a significant portion of the time since the onset of the disturbance, level of functioning in one or more major areas, such as work, interpersonal relations, or self-care, is markedly below the level achieved prior to the onset (or when the onset is in childhood or adolescence, there is failure to achieve expected level of interpersonal, academic, or occupational functioning) (American Psychiatric Association. 2013).Continuous signs of the disturbance persist for at least 6 months. This 6-month period must include at least 1 month of symptoms (or less if successfully treated) that meet Criterion A (i.e., active-phase symptoms) and may include periods of prodromal or residual symptoms. During these prodromal or residual periods, the signs of the disturbance may be manifested by only negative symptoms or by two or more symptoms listed in Criterion A present in an attenuated form (e.g., odd beliefs, unusual perceptual experiences) (American Psychiatric Association. 2013).Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out because either 1) no major depressive or manic episodes have occurred concurrently with the active-phase symptoms, or 2) if mood episodes have occurred during active-phase symptoms, they have been present for a minority of the total duration of the active and residual periods of the illness (American Psychiatric Association. 2013).The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (American Psychiatric Association. 2013).If there is a history of autism spectrum disorder or a communication disorder of childhood onset, the additional diagnosis of schizophrenia is made only if prominent delusions or hallucinations, in addition to the other required symptoms of schizophrenia, are also present for at least 1 month (or less if successfully treated) (American Psychiatric Association. 2013). The patient in this case study meets the DSM-V criteria for schizophrenia. He has been having disturbances at school and the onset appears to be over six months ago (Training video 29, 2016). “Full-blown positive symptoms during the first episode of psychosis are a diagnostic pillar of schizophrenia “(Millan et al., 2016). The positive symptoms the patient is displaying include delusional thinking, hallucinations, false beliefs, bizarre thoughts, suspiciousness and paranoia (Millan et al., 2016). Negative symptoms include poverty of speech and asociality as evidences by his lack of friends and staying in his dorm room (Training video 29, 2016). There is no evidence of substance abuse and he has no medical issues (Training video 29, 2016). The patientâ€s family history includes the grandmother having been hospitalized several times for psychiatric reasons (Training video 29, 2016). Genomic studies show schizophrenia to be a heritable disease (Millan et al., 2016), giving support to this diagnosis.The paranoid type of schizophrenia is characterized by preoccupation with delusions of persecution or grandeur or frequent auditory hallucinations (Sadock et al., 2015). In this case. the patient believes microwaves are killing people and that those who are with him are safe (Training video 29, 2016). These characteristics meet the criteria for paranoid type. According to Sadock et al, (2015), patients present as tense, suspicious, guarded, and can be hostile or aggressive. These characteristics are seen in the patient as well (Training video 29, 2016). Schizoaffective disorder DSM-V Diagnostic Criteria:An uninterrupted period of illness during which there is a major mood episode (major depressive or manic) concurrent with Criterion A of schizophrenia (American Psychiatric Association. 2013).Note: The major depressive episode must include Criterion A1: Depressed mood.Delusions or hallucinations for 2 or more weeks in the absence of a major mood episode (depressive or manic) during the lifetime duration of the illness (American Psychiatric Association. 2013).Symptoms that meet criteria for a major mood episode are present for the majority of the total duration of the active and residual portions of the illness (American Psychiatric Association. 2013).The disturbance is not attributable to the effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (American Psychiatric Association. 2013).The diagnosis of schizoaffective disorder shares psychotic symptoms with schizophrenia. However, schizoaffective disorder involves a concurrent mood disorder without a decline in role functioning (Hartman et al., 2019). The patient appears to be depressed as evidenced by his present mood and affect (Training video 29, 2016). However, an actual mood disorder is not diagnosed or apparent. Due to the lack of a clear mood disorder, this diagnosis is ruled out.Schizophreniform disorderDSM-V Diagnostic Criteria:Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated). At least one of these must be (1), (2), or (3):1.Delusions.2.Hallucinations. 3. Disorganized speech (e.g., frequent derailment or incoherence). 4. Grossly disorganized or catatonic behavior. 5. Negative symptoms (i.e., diminished emotional expression or avolition).(American Psychiatric Association. 2013).An episode of the disorder lasts at least 1 month but less than 6 months. When the diagnosis must be made without waiting for recovery, it should be qualified as “provisional.” (American Psychiatric Association. 2013).Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out because either 1) no major depressive or manic episodes have occurred concurrently with the active-phase symptoms, or 2) if mood episodes have occurred during active-phase symptoms, they have been present for a minority of the total duration of the active and residual periods of the illness (American Psychiatric Association. 2013).The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (American Psychiatric Association. 2013).The patient has displayed delusions, hallucinations, and disorganized speech. These symptoms are shared with schizophrenia. However, the criteria for the duration of the symptoms separate the two diagnoses (American Psychiatric Association. 2013). Schizophreniform is accompanied by a characteristic complex of psychotic symptomatology, including both positive and negative symptoms and cognitive deficits such as executive functioning, working memory, attention processes, and visuo-constructive impairments (Dauphin, 2017). Although the patient does have psychotic symptomology, there is no evidence of cognitive impairment (Training video 29, 2016). The patient meets the symptoms of schizophreniform. However, the timing rules out this disorder. ReflectionsThis case study involved a 19-year-old college student with psychotic symptoms. The primary diagnosis is schizophrenia, paranoid type. The assumption from the provided information was the symptoms had been present for at least a year. The synopsis talked about having anxiety and increased stress during his last year in high school. I would ask the patient about specific times the symptoms appeared in order to correctly differentiate between schizophrenic spectrum and other psychotic disorders (American Psychiatric Association, 2013). Another issue is not knowing the grandmotherâ€s diagnosis. If the patient is not able to give this information, the parents should be asked. Schizophrenia is a heritable disease (Millan et al., 2016). The auditory hallucinations were apparent; however, the content should be investigated. Are they command hallucinations? Are they persecutory hallucinations? Are the auditory hallucinations ever accompanied by visual hallucinations? This information may identify a suicidal crisis (Millan et al, 2016). Ethical ConsiderationsAn ethical principle in this case involves autonomy. Autonomy issues may include involving the patientâ€s parents in his treatment and taking away the patients right of self-governance. According to Beck & Ballon (2020), psychiatry is the primary discipline in which practitioners are often called upon to determine if a patient can make decisions on their own, which can be complex with schizophrenics. In this case study, the parents are the ones who noticed an issue with the patientâ€s behaviors and made an appointment for him to be evaluated (Training video 29, 2015). An example of an ethical privacy issue is the provider persuading the patient to involve their family members in their care if the patient wishes to be autonomous (Beck & Ballon, 2020). The patient in this case study has poor insight and reported not knowing why he needed to seek care (Training video 29, 2015). This may be a clear case of the patient not being capable of making safe autonomous decisions regarding his mental health. Health Promotion and Disease Prevention Treatment of schizophrenia disorders is typically antipsychotic medication. However, current interventions are aimed at complete physical, mental, and social well-being (Valiente et al., 2019). Subsequent therapies including psychological interventions such as cognitive behavioral therapy, can incorporate family interventions and social skills training that may promote an increase in quality of life (Valiente et al., 2019). In this case study, the patient is just beginning college and developing his individual identity. Utilization multiple interventions including medication management and psychological therapies will enable the patient to stabilize and promote an increased quality of life (Valiente et al., 2019).           ReferencesAmerican Psychiatric Association. (2013). Schizophrenia spectrum and other psychotic disorders. In Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author. doi:10.1176/appi.books.9780890425596.dsm02Beck, n. S., & Ballon, J. S. (2020). Ethical issues in schizophrenia. Focus: The Journal of Lifelong Learning in Psychiatry 18(4), pp 428-431. https://doi.org/10.1176/appi.focus.20200030Dauphin, J. (2017). Differentiation between schizophreniform configurations and psychotic personality structures. Psychodynamic Psychiatry, 45(2), 187–215. https://doi-org.ezp.waldenulibrary.org/10.1521/pdps.2017.45.2.187Hartman, L. I., Heinrichs, R. W., & Mashhadi, F. (2019). The continuing story of schizophrenia and schizoaffective disorder: One condition or two? Schizophrenia Research: Cognition, 16, pp 36–42. https://doi-org.ezp.waldenulibrary.org/10.1016/j.scog.2019.01.001Millan, M. J., Andrieux, A., Bartzokis, G., Cadenhead, K., Dazzan, P., Fusar-Poli, P., Gallinat, J., Giedd, J., Grayson, D. R., Heinrichs, M., Kahn, R., Krebs, M.-O., Leboyer, M., Lewis, D., Marin, O., Marin, P., Meyer-Lindenberg, A., McGorry, P., McGuire, P., … Weinberger, D. (n.d.). Altering the course of schizophrenia: progress and perspectives. Nature Reviews Drug Discovery, 15(7), 485–515. https://doi-org.ezp.waldenulibrary.org/10.1038/nrd.2016.28Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan & Sadockâ€s synopsis of psychiatry (11th ed.). Wolters Kluwer.“Training Title 29.”, directed by Anonymous, Symptom Media, (2016). Alexander Street, https://video-alexanderstreet-com.ezp.waldenulibrary.org/watch/training-title-29.Valiente, C., Espinosa, R., Trucharte, A., Nieto, J., & Martínez-Prado, L. (2019). The challenge of well-being and quality of life: A meta-analysis of psychological interventions in schizophrenia. Schizophrenia Research. https://doi-org.ezp.waldenulibrary.org/10.1016/j.schres.2019.01.040The post Comprehensive Psychiatric Evaluation and Patient Case Presentation appeared first on Nursing Term Paper.”Do you need a similar assignment done for you from scratch? We have qualified writers to help you with a guaranteed plagiarism-free A+ quality paper.Discount Code: SUPER50!”