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NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template Week (enter week #): (Enter assignment title) Student Name College of Nursing-PMHNP, Walden University NRNP 6635: Psychopathology and Diagnostic Reasoning Faculty Name Assignment Due Date Subjective: CC (chief complaint): HPI: Past Psychiatric History: · General Statement: · Caregivers (if applicable): · Hospitalizations: · Medication trials: · Psychotherapy or Previous Psychiatric Diagnosis: Substance Current Use and History: Family Psychiatric/Substance Use History: Psychosocial History: Medical History: · Current Medications: · Allergies: · Reproductive Hx: ROS: · GENERAL: · HEENT: · SKIN: · CARDIOVASCULAR: · RESPIRATORY: · GASTROINTESTINAL: · GENITOURINARY: · NEUROLOGICAL: · MUSCULOSKELETAL: · HEMATOLOGIC: · LYMPHATICS: · ENDOCRINOLOGIC: Objective: Physical exam: if applicable Diagnostic results: Assessment: Mental Status Examination: Differential Diagnoses: Reflections: References © 2021 Walden University Page 1 of 3 NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Exemplar INSTRUCTIONS ON HOW TO USE EXEMPLAR AND TEMPLATE—READ CAREFULLY If you are struggling with the format or remembering what to include, follow the Comprehensive Psychiatric Evaluation Template AND the Rubric as your guide. It is also helpful to review the rubric in detail in order not to lose points unnecessarily because you missed something required. Below highlights by category are taken directly from the grading rubric for the assignment in Weeks 4–10. After reviewing the full details of the rubric, you can use it as a guide. In the Subjective section, provide: · Chief complaint · History of present illness (HPI) · Past psychiatric history · Medication trials and current medications · Psychotherapy or previous psychiatric diagnosis · Pertinent substance use, family psychiatric/substance use, social, and medical history · Allergies · ROS · Read rating descriptions to see the grading standards! In the Objective section, provide: · Physical exam documentation of systems pertinent to the chief complaint, HPI, and history · Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses. · Read rating descriptions to see the grading standards! In the Assessment section, provide: · Results of the mental status examination, presented in paragraph form. · At least three differentials with supporting evidence. List them from top priority to least priority. Compare the DSM-5 diagnostic criteria for each differential diagnosis and explain what DSM-5 criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case . · Read rating descriptions to see the grading standards! Reflect on this case. Include: Discuss what you learned and what you might do differently. Also include in your reflection a discussion related to legal/ethical considerations ( demonstrate 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.). (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.) EXEMPLAR BEGINS HERE 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. First what is bringing the patient to your evaluation. Then, include a PSYCHIATRIC REVIEW OF SYMPTOMS. 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). A ssessment 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. You will use supporting evidence from the literature to support your rationale. 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 (move to begin on next page) 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. © 2021 Walden University Page 1 of 3 NRNP 6635 Case History Reports Use these case histories to supplement the information about the patients in the video case studies. Table of Contents Week 3: Mood Disorders........................................................................................................ 2 Training Title 2 ...............................................................................................................................2 Training Title 8 ...............................................................................................................................2 Training Title 18 .............................................................................................................................3 Training Title 28 .............................................................................................................................3 Training Title 38 .............................................................................................................................3 Training Title 43 .............................................................................................................................4 Training Title 150 ...........................................................................................................................4 Training Title 118 ...........................................................................................................................5 Training Title 144 ...........................................................................................................................5 Week 4: Anxiety Disorders, PTSD, and OCD ............................................................................ 6 Training Title 15 .............................................................................................................................6 Training Title 21 .............................................................................................................................6 Training Title 37 .............................................................................................................................7 Training Title 40 .............................................................................................................................7 Training Title 55 .............................................................................................................................7 Training Title 85 .............................................................................................................................8 Training Title 95 .............................................................................................................................8 Week 7 Schizophrenia and Other Psychotic Disorders; Medication-Induced Movement Disorders ............................................................................................................................... 9 Training Title 9 ...............................................................................................................................9 Training Title 24 .............................................................................................................................9 Training Title 29 .............................................................................................................................9 Training Title 134 ......................................................................................................................... 10 Week 8 Substance-Related and Addictive Disorders ............................................................. 11 Training Title 82 ........................................................................................................................... 11 Training Title 114 ......................................................................................................................... 11 Training Title 151 ......................................................................................................................... 12 Week 10 Neurocognitive and Neurodevelopmental Disorders .............................................. 12 Training Title 48 ........................................................................................................................... 12 Training Title 50 ........................................................................................................................... 12 Week 3: Mood Disorders Training Title 2 Name: Ms. Julie Houston Gender: female Age:19 years old T 98.1 P-78 R-18 119/74 Ht 5’2” Wt 184lbs Background: Recently started a business undergraduate program in Boston, MA after growing up and living in South Carolina her whole life. Grew up with both parents, two brothers, and one sister. Currently lives in off-campus housing with two other female roommates. Currently a full-time student, not employed. Not married, currently single. She has no previous psychiatric history; takes no medications. There is no psychiatric or substance use history for her or family. No legal hx NKDA Symptom Media. (Producer). (2016). Training title 2 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-2 Training Title 8 Name: Mrs. Leslie Tilman Gender: female Age: 32 years old T- 97.6 P- 97 R 22 149/98 Ht 5’3 Wt 245lbs Background: Recently had her first child two months ago. Currently married; stay at home mother after working in retail for 5 years. Grew up with both parents, one sister in Omaha, NE. Completed education through bachelor’s level, studying physics. Previous employment included research science as well as high school substitute teaching for 5 years prior to birth. No previous suicidal gestures; has uncle who committed suicide via GSW. She denied drugs/alcohol; uncle was opioid abuser. Hx of HTN-prescribed labetalol 100mg twice daily, admits to missing doses due to forgetting. No legal hx. Allergies: codeine Symptom Media. (Producer). (2016). Training title 8 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-8 https://video-alexanderstreet-com.ezp.waldenulibrary.org/watch/training-title-2 https://video-alexanderstreet-com.ezp.waldenulibrary.org/watch/training-title-2 https://video-alexanderstreet-com.ezp.waldenulibrary.org/watch/training-title-2 https://video-alexanderstreet-com.ezp.waldenulibrary.org/watch/training-title-8 https://video-alexanderstreet-com.ezp.waldenulibrary.org/watch/training-title-8 https://video-alexanderstreet-com.ezp.waldenulibrary.org/watch/training-title-8 Training Title 18 Name: Ms. Ashley Domingo Gender: female Age:20 years old T-97.9 P-68 R-18 118/82 Ht 5’1 Wt 120lbs Background: Currently living off-base in California, active duty in the Army, MOS 92M Mortuary Affairs Specialist. Grew up in Houston, TX with both parents and one brother. Completed education through high school. Currently partnered. No children. Mother history of depression; brother hx of cannabis use. No medical history. No legal hx; NKDA Symptom Media. (Producer). (2017). Training title 18 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-18 Training Title 28 Name: Mrs. Louise Carson Gender: female Age: 49 years old T- 98.8 P- 99 R 20 150/88 Ht 5’5 Wt 135lbs Background: Currently living in Indianapolis, IN, working full-time as a logistics buyer in a medical facility. Has an MBA. Lives with her husband and three children, three boys who are all teenagers. Born and raised in Indianapolis, IN with her mother and two sisters. Father deceased in MVA when she was 2 years old. Sister has depression; mother has history of being a “functioning alcoholic”. Recently informed by her PCP she has a “fatty liver.” Allergies: latex Symptom Media. (Producer). (2016). Training title 28 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-28 Training Title 38 (same patient in video 43 but presentation of his illness pre-hospitalization) Name: Mr. Will Loman Gender: male Age:19 years old T- 98.6 P- 94 R 24 128/78 Ht 5’7 Wt 152lbs Background: Currently lives with his sister and two parents in Jacksonville, FL. Not currently employed. Completed high school, not currently in school. Hx of treatment for mood disorder began age 15, previous trials of Depakote, Olanzapine off and on, side effects of wt. gain. Has hx of a three-day hospitalization one year ago after found wandering on the side of the freeway, but he signed himself out ‘against medical advice.’ He refused medication due to previous experiences. Not currently partnered. He has been sexually inappropriate with comments to female neighbors; pulled his pants down in the mall. Denies any recent alcohol or substance use. Father has history of bipolar disorder. No history of self-harm behaviors, no https://video-alexanderstreet-com.ezp.waldenulibrary.org/watch/training-title-18 https://video-alexanderstreet-com.ezp.waldenulibrary.org/watch/training-title-18 https://video-alexanderstreet-com.ezp.waldenulibrary.org/watch/training-title-18 https://video-alexanderstreet-com.ezp.waldenulibrary.org/watch/training-title-28 https://video-alexanderstreet-com.ezp.waldenulibrary.org/watch/training-title-28 https://video-alexanderstreet-com.ezp.waldenulibrary.org/watch/training-title-28 family suicides. Mother reports he has slept 2–3 hours in past week, up spending money buying and playing new video games and says he is writing a book on how others can be a video game master. Appetite is decreased. No medical hx; Hx of trespassing as a juvenile. Has pending court date for indecent exposure. Allergies: PCN Symptom Media. (Producer). (2016). Training title 38 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-38 Training Title 43 (same patient in video 38 but presentation of his illness with hospital treatment) Name: Mr. Will Loman Gender: male Age:19 years old T- 98.2 P- 74 R 18 120/70 Ht 5’7 Wt 156lbs Background: Currently lives with his sister and two parents in Jacksonville, FL. Not currently employed. Completed high school, not currently in school. Hx of treatment for mood disorder began age 15, previous trials of Depakote, Olanzapine off and on, side effects of wt. gain. Has hx of a three-day hospitalization one year ago after found wandering on the side of the freeway, but he signed himself out ‘against medical advice.’ He refused medication due to previous experiences. Not currently partnered. He has been sexually inappropriate with comments to female neighbors; pulled his pants down in the mall. He is currently in hospital admitted one week ago, was initiated on lithium 300mg po three times daily and risperidone 1mg at bedtime. Denies any recent alcohol or substance use. Father has history of bipolar disorder. No history of self-harm behaviors, no family suicides. Mother reports he has slept 2–3 hours in past week, up spending money buying and playing new video games and says he is writing a book on how others can be a video game master. Appetite is decreased. No medical hx; hospital admission labs within normal ranges, UDS negative; Hx of trespassing as a juvenile. Has pending court date for indecent exposure. Allergies PCN Symptom Media. (Producer). (2016). Training title 43 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-43 Training Title 150 Name: Ms. Liliana Ball Gender: female Age:16 years old T- 97.4 P- 84 R 18 134/88 Ht 5’3 Wt 118lbs Background: Currently living with her parents in Tacoma, WA along with two young siblings. She is a sophomore in high school, not currently partnered, reports she is bisexual, lately having lot https://video-alexanderstreet-com.ezp.waldenulibrary.org/watch/training-title-38 https://video-alexanderstreet-com.ezp.waldenulibrary.org/watch/training-title-38 https://video-alexanderstreet-com.ezp.waldenulibrary.org/watch/training-title-43 https://video-alexanderstreet-com.ezp.waldenulibrary.org/watch/training-title-43 https://video-alexanderstreet-com.ezp.waldenulibrary.org/watch/training-title-43 https://video-alexanderstreet-com.ezp.waldenulibrary.org/watch/training-title-150 of unprotected sex that her parents don’t know about. She has been stealing money out of her mom’s purse to buy clothes, makeup, “and just other things.” She has history of treatment since age 7 for conduct disorder, depression, history of taking sertraline which worsened her irritability, aggression, impulsivity. She has been in a 3-month teen residential mental health facility discharged one month ago with lithium 300mg in am and 600mg at bedtime, aripiprazole 10mg in the morning. When discharged, her labs were within normal ranges and urine toxicology negative. She was positive for cannabis upon admission. Her parents believe she is hiding her medication as she has made comments “they slow me down; they crush my creative art.” She has hx of domestic violence toward her mother and 2 younger sisters as juvenile. No current legal issues. Her grandmother has hx of bipolar disorder; her mother and her maternal aunt have anxiety. She is sleeping 3–4hrs/24 hrs. Reports her appetite “is great.” She has no medical issues; has Nexplanon implant; hx of self-harm with cutting. Symptom Media. (Producer). (2018). Training title 150 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-150 Training Title 118 Name: Mr. Oscar Luna Gender: male Age: 52 years old T- 98.6 P- 90 R 24 140/84 Ht 5’8 Wt 170lbs Background: Born and raised in Leopold, IN. Is staying at a shelter after being homeless in MacArthur Park for 1 year in Los Angeles. He lost his apartment and his job working part-time as a dishwasher. Enjoys playing music. He has long hx of mental health treatment since age 14. Previous medication trials include lithium (toxicity), Depakote (wt gain), aripiprazole (akathisia), risperidone (dystonia), haloperidol (didn’t give a fair trial), quetiapine (wt gain), reports in past helpful medication was lurasidone, lamotrigine, olanzapine but states “they really squash my creative song writing though.” Poor historian. Never married, reports he is gay, no children; estranged from only living sister, parents deceased. He is not sure of his family mental health or substance use history but feels like he is most like his aunt, she has history of mental health treatment “but I’m not sure for what.” States that he got a master’s degree in music theory at Stanford. Admits to 1–3 drinks of alcohol when “playing music in the clubs”, denied illicit drugs, has history of overdose at age 28, history of 3 inpatient psychiatric hospitalization, most recent was 1 year ago. Allergies: doxycycline; hx of rosacea. Symptom Media. (Producer). (2018). Training title 118 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-118 Training Title 144 Name: Ms. Amy Hartford Gender: female https://video-alexanderstreet-com.ezp.waldenulibrary.org/watch/training-title-150 https://video-alexanderstreet-com.ezp.waldenulibrary.org/watch/training-title-150 https://video-alexanderstreet-com.ezp.waldenulibrary.org/watch/training-title-118 https://video-alexanderstreet-com.ezp.waldenulibrary.org/watch/training-title-118 https://video-alexanderstreet-com.ezp.waldenulibrary.org/watch/training-title-118 https://video-alexanderstreet-com.ezp.waldenulibrary.org/watch/training-title-144 Age: 32 years old T- 98.2 P- 74 R 18 120/70 Ht 5’1 Wt 150lbs Background: Currently lives in Phoenix, AZ, divorced with two children ages 10 and 8. Born and raised in Tucson, AZ with her mother and four sisters NKDA; no legal hx Symptom Media. (Producer). (2018). Training title 144 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-144 Week 4: Anxiety Disorders, PTSD, and OCD Training Title 15 Name: Mr. David Jackson Gender: male Age:19 years old T- 98.8 P- 89 R 18 110/62 Ht 5’7 Wt 133lbs Background: Lives in Minneapolis, MN with both of his parents, only child. Works part time at Starbucks. Not currently partnered. No previous psychiatric history. Symptoms began in the last 1.5 months when he discovered he is being activated with the Navy Reserves. His MOS is SK1 Storekeeper; no medical illnesses Allergies: NKDA; sleeps 6.5 hrs; appetite good Symptom Media. (Producer). (2017). Training title 15 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-15 Training Title 21 Name: Sergeant Patrick Flanrey Gender: male Age:27 years old T- 97.4 P- 84 R 18 B/P134/88 Ht 5’8 Wt 167lbs Background: He entered the military just after high school and did three long tours of duty in warzones. He separated from active duty in the Marines (MOS 0800 Field Artillery) less than a year ago after eight years of service. He is engaged to be married (no date set) and is currently working as a furniture salesman. He said he grew up poor and would not do much else if he didn’t go into the military. He denies ever using any drugs and avoids alcohol because his father was “sloppy drunk.” Father is still alive, unwell (DM, liver disease, HTN), still drinking. Paternal grandfather was also a veteran and suffered depression at times though he never told anyone except the patient because of their combat connection. Mother is alive and well, still “caring for dad.” He has one younger and one older sister. He lives in a different state, approximately five hours from his parents and siblings. After the military, he and his fiancé moved because she got a much better opportunity. They want kids someday and hope to marry https://video-alexanderstreet-com.ezp.waldenulibrary.org/watch/training-title-144 https://video-alexanderstreet-com.ezp.waldenulibrary.org/watch/training-title-144 https://video-alexanderstreet-com.ezp.waldenulibrary.org/watch/training-title-15 https://video-alexanderstreet-com.ezp.waldenulibrary.org/watch/training-title-15 in a year or two. Has service-connected asthma, seasonal allergies; no hx of psychiatric or substance use treatment. Symptom Media. (Producer). (2016). Training title 21 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-21 Training Title 37 Name: Mr. Tony Patelli Gender: male Age:18 years old T- 98.8 P- 94 R 20 126/88 Ht 5’4 Wt 131lbs Background: Lives alone in New York, raised by parents in New Jersey, only child. He is a full- time student at local community college for graphic design. Has a girlfriend from high school. No previous psychiatric history. No medical illnesses; no history of psychiatric treatment; denied drugs or alcohol; Allergies: NKDA; sleeps 7.5 hrs; appetite eats 3 meals/day, likes to keep a routine schedule. Symptom Media. (Producer). (2016). Training title 37 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-37 Training Title 40 Name: Ms. Barbara Weidre Gender: female Age: 56 years old T- 99.0 P- 99 R 24 132/89 Ht 5’4 Wt 168lbs Background: Lives with her husband in Knoxville, TN, has one daughter age 23. She has never worked. Raised by mother, she never knew her father. Mother with hx of anxiety; no substance hx for patient or family. No previous psychiatric treatment. Has one glass red wine with dinner. Sleeps 10-12 hrs; appetite decreased. Has overactive bladder, untreated. Allergic to Phenergan; complains of headaches, takes prn ibuprofen, has diarrhea once weekly, takes OTC Imodium. Symptom Media. (Producer). (2016). Training title 40 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-40 Training Title 55 Name: Matilda Johnson Gender: female Age: 9years old She refused vitals, ht and wt https://video-alexanderstreet-com.ezp.waldenulibrary.org/watch/training-title-21 https://video-alexanderstreet-com.ezp.waldenulibrary.org/watch/training-title-21 https://video-alexanderstreet-com.ezp.waldenulibrary.org/watch/training-title-37 https://video-alexanderstreet-com.ezp.waldenulibrary.org/watch/training-title-37 https://video-alexanderstreet-com.ezp.waldenulibrary.org/watch/training-title-40 https://video-alexanderstreet-com.ezp.waldenulibrary.org/watch/training-title-40 Vaccinations are up to date; on target with developmental milestones. Appetite, she is a picky eater per mom. NKDA Symptom Media. (Producer). (2017). Training title 55 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-55 Training Title 85 Name: Mrs. Carol Holliman Gender: female Age: 42 years old T- 98.0 P- 77 R 18 132/72 Ht 5’0 Wt 127lbs Background: Born and raised in Northern Ireland, parents brought her and her 5 sisters to U.S. when she was 15 to go to U.S. university where she met her husband. They live in Charleston, SC. She obtained her bachelor’s degree in education; no history of mental health or substance use treatment, no family history. Her husband reported a recent school shooting nearby 3 weeks ago “flipped a switch” in her. She is watching the news 24/7, barely sleeping, and even when she does, it is only a few hours, Appetite is decreased. Hx of hysterectomy, NKDA, no legal hx. Symptom Media. (Producer). (2017). Training title 85 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-85 Training Title 95 Name: Ms. Zahara Williams Gender: female Age: 23 years old T- 97.5 P- 86 R 18 112/64 Ht 5’2 Wt 130lbs Background: Born and raised in Jacksonville, FL with her mother and 2 older brothers; her mother has hx of anxiety, brothers hx of cannabis; no previous mental health treatment, no medications; NKDA; no legal hx; sleeping 7 hrs; Appetite is good. She has an associate of arts degree and works for Amazon warehouse. She has DX of diabetes since age 5. She recalls having great difficulty with her medical condition (uncontrolled blood sugar, fighting with mother over needle sticks, “kids want candy, and I was so different because of my diet”). She recalls having a difficult relationship with her mother who was a nurse and really worked hard to control her daughter’s diabetes. She is not in a relationship, identifies as lesbian but has not come out to the family. Only her closest co-workers know she is gay, and she doesn’t plan to come out in the near future. She stated, “I don’t see why I would, they wouldn’t understand, and this is not important right now.” Symptom Media. (Producer). (2018). Training title 95 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-95 https://video-alexanderstreet-com.ezp.waldenulibrary.org/watch/training-title-55 https://video-alexanderstreet-com.ezp.waldenulibrary.org/watch/training-title-55 https://video-alexanderstreet-com.ezp.waldenulibrary.org/watch/training-title-85 https://video-alexanderstreet-com.ezp.waldenulibrary.org/watch/training-title-85 https://video-alexanderstreet-com.ezp.waldenulibrary.org/watch/training-title-95 https://video-alexanderstreet-com.ezp.waldenulibrary.org/watch/training-title-95 Week 7 Schizophrenia and Other Psychotic Disorders; Medication- Induced Movement Disorders Training Title 9 Name: Ms. Nijah Branning Gender: female Age: 25 years old T- 98.4 P- 80 R 18 128/78 Ht 5’0 Wt 120lbs Background: Raised by parents, lives alone in Santa Monica, CA. Only child. Works in office supply sales, has a bachelor’s in business degree. Has medical history of hypothyroidism, currently treated with daily levothyroxine. Guarded and declined to discuss past psychiatric history. Denied family mental health issues, declined to allow you to speak to parents for collaborative information. Allergies: medical tape; menses regular Symptom Media. (Producer). (2016). Training title 9 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-9 Training Title 24 Name: Ms. Jess Cunningham Gender: female Age: 28 years old T- 98.6 P- 86 R 20 120/70 Ht 5’2 Wt 126lbs Background: Jess is brought for evaluation by her 2 roommates who are concerned with behaviors that began 12 days after Jess’s younger brother committed suicide in front of her via GSW after his girlfriend broke up with him. She is estranged from her parents and her brother was her only sibling. She is only sleeping 1–2 hours/24hrs; she will only canned foods. She smokes cannabis daily since she was 16, goes out on weekdays 2–3 times with her roommates and has couple drinks of beer. She was prescribed alprazolam 1mg twice daily as needed by her PCP for 15 days. She works as a bartender. Symptom Media. (Producer). (2016). Training title 24 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-24 Training Title 29 Name: Mr. Jay Feldman Gender: male Age:19 years old https://video-alexanderstreet-com.ezp.waldenulibrary.org/watch/training-title-9 https://video-alexanderstreet-com.ezp.waldenulibrary.org/watch/training-title-9 https://video-alexanderstreet-com.ezp.waldenulibrary.org/watch/training-title-24 https://video-alexanderstreet-com.ezp.waldenulibrary.org/watch/training-title-24 T- 98.3 P- 69 R 16 106/72 Ht 5’7 Wt 117lbs Background: European-American male. He has two younger brothers, one with history of ADHD, the other with history of anxiety. His mother has anxiety; his father has paranoia schizophrenia. He is home for spring break. He has no previous medical problems. Developmental milestones met as child. Appetite is inconsistent and it seems he has lost 18lbs since first going back to school in the fall. Jason has not acted this way before but did have a short trial of aripiprazole in the last six months of high school for mild paranoia. He stopped the medication after graduation as he could not tolerate due to side effects of akathisia. Jason has several friends but has not kept in touch with them since being back home. He has not been showering. Sleeping 4–5 hrs. Symptom Media. (Producer). (2016). Training title 29 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-29 Training Title 134 Name: Mrs. Bunny Warren Gender: female Age: 33 years old Background: Bunny was brought in by her best friend, Patty, after the police responded to her home the fifth time today. The police was threatening to arrest her for misuse of the 911 system, Bunny called you and you informed the police she needed to go the emergency room. She has been calling 911 saying people are looking in her windows, standing across the street watching her, stated they are watching for her husband to return home so they can hurt him. Today, she has a stomachache. She believes there is a snake inside of her stomach which she would like to have removed. She stopped eating 2 days ago because of this. During the assessment, the patient seemed on edge, anxious, and paranoid. The patient has history of scoliosis. This is her third presentation to this hospital, she had one psychiatric admission 2 years ago. No self-harm behaviors but has been physically aggressive toward others in the past. She is guarded and refuses to answer questions whether there are memory or concentration problems. She denies any recent head injuries. She states that she has been sleeping nightly, one or two hours at a time and waking up throughout the night. Refuses labs, refuses to have her vital signs obtained. She obtains SSDI. She lives in Atlanta, GA. Bunny denies ever using any drugs and drinks occasionally, once a month. She has a sister who is ten years older, both parents deceased in the last two years. She has no children, her husband is out of town, truck driver. Family history includes that her father had two previous inpatient psychiatric hospitalizations after bad drug experiences in the 1970s, for one week each time. Mother had diagnosis and ongoing treatment for depression. Her paternal grandmother was state hospitalized for several years. https://video-alexanderstreet-com.ezp.waldenulibrary.org/watch/training-title-29 https://video-alexanderstreet-com.ezp.waldenulibrary.org/watch/training-title-29 She denies any past history of traumatic experiences, but her friend does say that losing her parents was hard for her emotionally. No history of military service. No legal issues currently. Has HS diploma. Allergies: haloperidol Symptom Media. (Producer). (2018). Training title 134 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-134 Week 8 Substance-Related and Addictive Disorders Training Title 82 Name: Lisa Pittman Gender: female Age: 29 years old T- 99.8 P- 101 R 20 178/94 Ht 5’6 Wt 140lbs Background: Lisa is in a West Palm Beach, FL detox facility thinking about long term rehab. She has been smoking crack cocaine, approximately $100 daily. … Assignment: Assessing and Diagnosing Patients with Mood Disorders Accurately diagnosing depressive disorders can be challenging given their periodic and, at times, cyclic nature. Some of these disorders occur in response to stressors and, depending on the cultural history of the client, may affect their decision to seek treatment. Bipolar disorders can also be difficult to properly diagnose. While clients with a bipolar or related disorder will likely have to contend with the disorder indefinitely, many find that the use of medication and evidence-based treatments have favorable outcomes. To Prepare: · Review this week’s Learning Resources. Consider the insights they provide about assessing and diagnosing mood disorders. · Download the Comprehensive Psychiatric Evaluation Template, which you will use to complete this Assignment. Also review the Comprehensive Psychiatric Evaluation Exemplar to see an example of a completed evaluation document.  · View your assigned video case and review the additional data for the case in the “Case History Reports” document, keeping the requirements of the evaluation template in mind. · Assigned video https://video-alexanderstreet-com.ezp.waldenulibrary.org/watch/training-title-2/transcript?context=channel:test-section-index · Consider what history would be necessary to collect from this patient. · Consider what interview questions you would need to ask this patient. · Identify at least three possible differential diagnoses for the patient.  Complete and submit your Comprehensive Psychiatric Evaluation, including your differential diagnosis and critical-thinking process to formulate a primary diagnosis. Incorporate the following into your responses in the template: · Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What is 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 with supporting evidence, listed in order from highest priority to lowest priority. Compare the DSM-5 diagnostic criteria for each differential diagnosis and explain what DSM-5 criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case. · Reflection notes: What would you do differently with this client if you could conduct the session over? Also include in your reflection a discussion related to legal/ethical considerations (demonstrate 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.). Learning Resources https://video-alexanderstreet-com.ezp.waldenulibrary.org/watch/depressive-disorders https://video-alexanderstreet-com.ezp.waldenulibrary.org/watch/mood-disorders https://video-alexanderstreet-com.ezp.waldenulibrary.org/watch/bipolar-disorders Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan & Sadock’s synopsis of psychiatry (11th ed.). Wolters Kluwer. · Chapter 8, Mood Disorders · Chapter 31, Child Psychiatry (Section 31.12 only)