Task 2: Comprehensive Psychiatric Assessment and Patient Case Presentation
For this Task, you’ll doc details about a affected person that you just examined over the last three weeks, utilizing the Comprehensive Psychiatric Assessment Template supplied. You’ll then use this be aware to develop and document a case presentation for this affected person. You should definitely incorporate any suggestions you acquired in your Week three and Week 6 case displays into this ultimate presentation for the course.
To Put together
• Assessment this week’s Studying Assets and contemplate the insights they supply. Additionally Assessment the Kaltura Media Uploader useful resource within the left-hand navigation of the classroom for Help creating your self-recorded Kaltura video.
• Choose a affected person that you just examined over the last three weeks who introduced with a dysfunction for which you haven’t already carried out an analysis in Weeks three or 6. (As an illustration, in case you chosen a affected person with OCD in Week 6, you should select a affected person with one other kind of dysfunction for this week.) Conduct a Comprehensive Psychiatric Assessment on this affected person utilizing the template supplied within the Studying Assets. There’s additionally a accomplished exemplar doc within the Studying Assets as a way to see an instance of the forms of info a accomplished analysis doc ought to include. All psychiatric Assessments should be signed, and every web page should be initialed by your Preceptor. Once you submit your doc, you need to embody the whole Comprehensive Psychiatric Assessment as a Phrase doc, in addition to a PDF/photos of every web page that’s initialed and signed by your Preceptor. You should submit your doc utilizing SafeAssign. Please Be aware: Digital signatures usually are not accepted. If each recordsdata usually are not acquired by the due date, School will deduct factors per the Walden Late Insurance policies.
• Then, based mostly in your analysis of this affected person, develop a video case presentation that features chief grievance; historical past of current sickness; any pertinent previous psychiatric, substance use, medical, social, household historical past; most up-to-date psychological standing examination; and present psychiatric analysis together with differentials that had been dominated out.
• Embody a minimum of 5 (5) scholarly assets to help your Assessment and diagnostic reasoning.
• Guarantee that you’ve the suitable lighting and tools to document the presentation
Task
File your self presenting the advanced case to your medical affected person. In your presentation:
• Costume professionally and current your self in an expert method.
• Show your picture ID initially of the video whenever you introduce your self.
• Be sure that you don’t embody any info that violates the rules of HIPAA (i.e., don’t use the affected person’s identify or another figuring out info).
• Current the total case. Embody chief grievance; historical past of current sickness; any pertinent previous psychiatric, substance use, medical, social, household historical past; most up-to-date psychological standing examination; and present psychiatric analysis together with differentials that had been dominated out.
• Report regular diagnostic outcomes because the identify of the take a look at and “regular” (slightly than particular worth). Irregular outcomes ought to be reported as a selected worth.
Be succinct in your presentation, and don’t exceed eight minutes. Handle the next:
• Subjective: What particulars did the affected person present relating to their private and medical historical past? What are their signs of concern? How lengthy have they been experiencing them, and what’s the severity? How are their signs impacting their functioning?
• Goal: What observations did you make through the interview and Assessment of methods?
• Assessment: What had been your differential diagnoses? Present a minimal of three (three) doable diagnoses. Listing them from highest to lowest precedence. What was your major analysis, and why?
• Reflection notes: What would you do otherwise in the same affected person analysis?
CASE STUDY
Identify KB
Age 22years
Individuals Current in SessionThe affected person was current within the session. The affected person is just not a medical choice maker and bodily attended the session.
Chief Criticism
“Want a brand new psychiatrist”.
Began having having anxiousness and melancholy after mother and father divorced. Was having problem
concentrating, problem sleeping, unhappy temper, a number of suicidal makes an attempt in center faculty, Temper
swings largely round interval. Admit to a number of panic assaults. Hallucinations and delusion however
thinks is expounded to taking hydroxyzine. Seen a therapist in when in seventh grade, psychiatrist since excessive
faculty. Presently taking hydroxyzine, trazodone, paroxetine. Psychiatrist thought affected person additionally had
bipolar however by no means was recognized and was additionally recognized with binge dysfunction. Having melancholy
years, worsened final month. Extra 10 lifetime episodes. Depressed most days of the week. Dry mouth and constipation
PHQ-9 (Complete: 26)
GAD-7 (Complete: 18)
MoodDQ (Q1 Complete: 12, Q2 Complete: 1, Q3 Complete: 2)
The affected person denied household historical past of bipolar dysfunction. The affected person endorsed being recognized with
bipolar dysfunction, experiencing a number of of those signs without delay, and having reasonable issues
with work or social perform. The affected person endorsed experiencing a time frame the place they had been
not their regular self, with the next signs: having extra vitality, uncommon self-confidence,
decreased want for sleep, and racing ideas, elevated productiveness, being unusually social and
irritable, being hyper-sexual and simply distracted, taking part in dangerous conduct, happening spending
sprees, and experiencing pressured speech.
The affected person denied experiencing: hyperactivity .
ASRS-V1.1 (Complete: 56, Half A: 5, Half B: 10)
Stressors
No proof of acute threat of hurt to self or others
Suicide
paroxetine HCl (paroxetine
hcl)
RUBRIC
The coed gives an correct, clear, and full description of the chief grievance and historical past of current sickness.
Description of previous psychiatric, substance use, medical, social, and household historical past
Dialogue of most up-to-date psychological standing examination and observations made throughout interview and Assessment of methods
The coed gives an correct, clear, and full dialogue of diagnostics with outcomes.
The coed gives an correct, clear, and full analysis with three (three) differentials.
The response clearly, precisely, and completely follows the Comprehensive Psychiatric Assessment format to doc the chosen affected person case.
