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Comprehensive Psychiatric Evaluation Note and Patient Case Presentation

Comprehensive Psychiatric Evaluation Note and Patient Case Presentation

Assignment 2: Comprehensive Psychiatric Evaluation Note and Patient Case Presentation

Psychiatric notes are a way to reflect on your practicum experiences and connect the experiences to the learning you gain from your weekly Learning Resources. 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 at your practicum site, using the Comprehensive Psychiatric Evaluation Note Template provided. You will then use this note to develop and record a case presentation for this patient.

 

Case study:

 

(Female, 16, Anxiety Disorder, (DMDD) Disruptive mood dysregulation disorder)

 

16-years-old Afro-American female with history of DMDD and sickle cell disease. Patient is accompanied by her foster mother. Today is patient’s fifth visit to the clinic. Patient has a long history of mental hospitalizations as well as medical admissions. Patient last admitted to the hospital was 3 weeks ago for three days as she had a sickle cell crisis.

Patient was removed from his parents at the age of 6 due to negligence and physical abuse. Foster mother report that she is ‘uncontrollable” at home and when thing doesn’t going her way she destroyed dishes and furniture. Patient had been running away from home twice in the past year. 2 years ago she was found playing with the gas stove and started a small fire. She likes to play rude and pulls the family cat around by its tail. Patient has been in two different foster homes, the last one since she was 11 years old. The foster mother described a several-year history of aggressive and destructive behavior as well as four school suspensions during the past year.

On today’s session patient is well dress, AAO x 3, seems distracted and without interest of answer questions or participate. Patient denies suicidal or homicidal ideations, intentions or plan, also denies auditory, visual or tactile hallucinations. As per foster mother, patient is being disrespectful and restless at home. She also report that the patient is starting fights at school with her peers. Patient refused to talk about it. During the session, the clinician facilitated a discussion about stress management and impulse control techniques. Psychoeducation provided regarding clarifying areas of difficulty and identifying coping skills. The clinician provided psychoeducation regarding medication compliance, and patient / caregiver were receptive. The patient was encouraged to continue follow-up psychotherapy to monitor her mood. Individual psychotherapy is scheduled for next week.

 

Instructions:

 

Create a Comprehensive Psychiatric Evaluation Note on this patient using the template provided. There is also a completed template provided as an exemplar and guide.

 

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.

 

**Include at least five scholarly resources to support your assessment and diagnostic reasoning. **

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