Assignment 2: Comprehensive Psychiatric Assessment and Patient Case Presentation
For this Assignment, you will document information about a patient that you examined during the last 3 weeks, using the Comprehensive Psychiatric Assessment Template provided. You will then use this note to develop and record a case presentation for this patient. Be sure to incorporate any feedback you received on your Week 3 and Week 6 case presentations into this final presentation for the course.
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 for which you have not already conducted an Assessment in Weeks 3 or 6. (For instance, if you selected a patient with OCD in Week 6, you must choose a patient with another type of disorder for this week.) Conduct a Comprehensive Psychiatric Assessment 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 Assessment document should contain. All psychiatric Assessments must be signed, and each page must be initialed by your Preceptor. When you submit your document, you should include the complete Comprehensive Psychiatric Assessment 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.
• Then, based on your Assessment of this patient, develop a video case presentation 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 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 Assessment?
CASE STUDY
Name KB
Age 22years
Persons Present in SessionThe patient was present in the session. The patient is not a medical decision maker and physically attended the session.
Chief Complaint
“Need a new psychiatrist”.
Started having having anxiety and depression after parents divorced. Was having difficulty
concentrating, difficulty sleeping, sad mood, multiple suicidal attempts in middle school, Mood
swings mostly around period. Admit to multiple panic attacks. Hallucinations and delusion but
thinks is related to taking hydroxyzine. Seen a therapist in when in 7th grade, psychiatrist since high
school. Currently taking hydroxyzine, trazodone, paroxetine. Psychiatrist thought patient also had
bipolar but never was diagnosed and was also diagnosed with binge disorder. Having depression
years, worsened last month. More 10 lifetime episodes. Depressed most days of the week. Dry mouth and constipation
PHQ-9 (Total: 26)
GAD-7 (Total: 18)
MoodDQ (Q1 Total: 12, Q2 Total: 1, Q3 Total: 2)
The patient denied family history of bipolar disorder. The patient endorsed being diagnosed with
bipolar disorder, experiencing several of these symptoms at once, and having moderate problems
with work or social function. The patient endorsed experiencing a period of time where they were
not their usual self, with the following symptoms: having excess energy, unusual self-confidence,
decreased need for sleep, and racing thoughts, increased productivity, being unusually social and
irritable, being hyper-sexual and easily distracted, participating in risky behavior, going on spending
sprees, and experiencing pressured speech.
The patient denied experiencing: hyperactivity .
ASRS-V1.1 (Total: 56, Part A: 5, Part B: 10)
Stressors
No evidence of acute risk of harm to self or others
Suicide
paroxetine HCl (paroxetine
hcl)
RUBRIC
The student provides an accurate, clear, and complete description of the chief complaint and history of present illness.
Description of past psychiatric, substance use, medical, social, and family history
Discussion of most recent mental status exam and observations made during interview and review of systems
The student provides an accurate, clear, and complete discussion of diagnostics with results.
The student provides an accurate, clear, and complete diagnosis with three (3) differentials.
The response clearly, accurately, and thoroughly follows the Comprehensive Psychiatric Assessment format to document the selected patient case.
