PRAC 6635 WEEK 5 ASSIGNMENT 2 PART 2: COMPREHENSIVE PSYCHIATRIC EVALUATION AND PATIENT CASE PRESENTATION, DOCUMENTATION
PRAC 6635 WEEK 5 ASSIGNMENT 2 PART 2: COMPREHENSIVE PSYCHIATRIC EVALUATION AND PATIENT CASE PRESENTATION, DOCUMENTATION
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.
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For this Assignment, you will document information about a patient that you examined during the last 5 weeks, using the Comprehensive Psychiatric Evaluation Template provided. You will then use this note to develop and record a case presentation for this patient.
RESOURCES
Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.
TO PREPARE
- Select a patient that you examined during the last 2 weeks. Review prior resources on the disorder this patient has.
- 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.
- Include at least five (5) scholarly resources to support your assessment and diagnostic reasoning.
- 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? 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 (5) scholarly resources to support your assessment and diagnostic reasoning.
J.R. 73-year-old female: Current diagnoses:
· Depression
· Anxiety
Lifestyle: former smoker, no children, been married 21 years. She used to be a receptionist. High school education. Both parents died, mom had depression and brother. A sister has depression. She’s estranged from her siblings. She didn’t want to talk too much about past history.
-Never been hospitalized. No SI attempts.
-Not seeing a therapist
-Support system: The husband helps cook and clean.
-Current Meds: Zoloft, Remeron, Xanax (oxybutin, protonix, levothyroxine, vit B12, iron, lisinopril, Lipitor,)
Recent Soap Note
Subjective
PMHNP: What brings you in today? The reason I am here today is because I have suffered with depression since my 20s it tends to be in my family so it’s no surprise however what brings me here today is I’ve been going through a really bad time. I’ve had a lot of health problems and you mixed health problems with depression it’s not a pretty picture. To add fuel to the fire back in early July my my my hair started to fall out I woke up one morning and hair was on my pillowcase needless to say I haven’t been right since this thing has thrown me over the edge. I’ve always considered myself, I’ve always taken good care of myself and I’ve always taken pride in my appearance. I wouldn’t say maybe I was a little vain I think we all are you like to look nice. OK so anyway when I woke up that morning and hair was on my pillow, I think it was the beginning of the end of Janice that people have known. It’s done something to me.
PMHNP: did they find out why you’re losing your hair? Yeah it took a little while but I went to my primary care doctor according to him I had a deficiency in my iron and my B-12 so he put me on medicine. I’ve been on it for a long time I also went to a dermatologist he has a different take on why he thinks my hair fell out, he thinks it’s from a lot of stress. And to add fuel to the fire, I blame myself in a sense and he tells me not to, that this has nothing to do with anything I’ve done but I feel maybe in a way it was the stress.
PMHNP: Let’s talk about that because as you know that’s often linked to anxiety you mentioned you had anxiety for so long can you tell me about the anxiety? can you give me a little history of that ? Well as I said as of last year I got a lot of health problems, you’re talking to a woman here who used to go dancing three times a week OK I love to dance I love to draw. I love to read I look at myself now and it’s like I’m just a totally different person.
PMHNP: when was the last time you did any of that drawing dancing reading? I’ll be honest with you I don’t do much of anything since one I just my husband and I have enough things to deal with you know between errands and doctor appointments and you know it’s we just have a lot to keep us busy. To add fuel to the fire, his health hasn’t been that good either he’s on his diabetic meds which I find very stressful. If his numbers are off and of course they were off yesterday I find myself getting very upset but with diabetes you’re gonna have your good days and you’re not so good days.
PMHNP: So the anxiety, how many years you’ve had that diagnosis for the anxiety do you know how many years you’ve had that diagnosis?.. I’ve had depression since my 20s I wasn’t quite on an antidepressant, I think it’s when my father passed away and was put on paxil and I did very well on it.
-Father passed away in 1998 -came off the paxil after 20 years, after going to another provider for help who felt at that time the paxil wasn’t working and that she should go off it. Was weaned off and tried on: zoloft 50mg which she reports is hard to say if its working or not as she has been on it for quite some time. Also on mirtazapine 30mg for sleep which helps her sleep. Her depression from the time she gets up until bedtime around 6p, when she takes the mirtazapine she feels much better, more relaxed, has an appetite and helps her sleep.
-Has an appointment to see a motility doctor to explore why she can’t gain weight or keep anything down. She has lost a lot of weight. previously 120lbs and now doesn’t want to know what she weighs. She is also on xanax started last year after going through a withdrawal from “something” thinks possibly the paxil and went into a horrible depression to take the edge off and it helped. takes 0.25mg three times a day as needed.
Diagnostic test:
PHQ 9 screen RESULT SUMMARY: 24 points
Scores 20 and greater suggest severe depression; patients typically should have immediate initiation of pharmacotherapy and expedited referral to mental health specialist.
GAD-7 (General Anxiety Disorder-7) RESULT SUMMARY: 19 points
Severe anxiety disorder.
PAST PSYCHIATRIC HISTORY: •O/P Psychiatrist/therapists: •Previous diagnosis: depression, anxiety, •Previous admissions: denies •Previous suicide attempts: denies •Past Medication History: see hpi SUBSTANCE ABUSE HISTORY: •Tobacco: past social smoker, stopped many years ago •ETOH/CAGE: last drink been too long https://qxmd.com/calculate/calculator_481/cage-questionnaire •Illicit Drugs: denies •Rehab Programs: denies SOCIAL HISTORY: •Living Situation: lives with husband •Marital History: married 21 years ago •Children: no children •Occupation: retired, office worker, receptionist •Education: high school •Parents: both deceased-depression runs in her family, mom with depression, father not sure •Siblings: brother with depression, 2 sisters estranged •Family Psychiatric History: see above •History of Abuse/Legal History: denies
REVIEW OF SYSTEMS: CONSTITUTIONAL: See HPI. No night sweats. No fatigue, malaise, lethargy. No fever or chills. HEENT: Eyes: No visual changes. No eye pain. No eye discharge. ENT: No runny nose. No epistaxis. No sinus pain. No sore throat. No ear pain. No congestion. BREASTS: No breast pain, soreness, lumps, or discharge. RESPIRATORY: No cough. No wheeze. No hemoptysis. No shortness of breath. CARDIOVASCULAR: No chest pains. No palpitations. GASTROINTESTINAL: No abdominal pain. No nausea or vomiting, diarrhea or constipation. GENITOURINARY: No urgency. No frequency. No dysuria. No hematuria. MUSCULOSKELETAL: No musculoskeletal pain. No joint swelling. NEUROLOGICAL: No headache or neck pain. No syncope or seizure. PSYCHIATRIC: See HPI SKIN: No rashes. No lesions. No wounds. ENDOCRINE: No unexplained weight loss. No polydipsia. No polyuria. No polyphagia. HEMATOLOGIC: No anemia. No prolonged or excessive bleeding. ALLERGIC AND IMMUNOLOGIC: No pruritus. No swelling.
Functionally, the patient finds it is “very difficult” to perform life tasks due to their symptoms.
Objective:
anxious appearing, appears older than stated age, very thin, frail appearing, tremulous and voice shakes due to anxiety, emotional, tearful, upset at times, guarded at times, tangential.
Assessment
did well on paxil for 20 years then had a bout of depression and PCP tried her on a couple of other meds but then referred her to psychiatrist who then took her off paxil which caused withdrawal and extreme anxiety causing them to add xanax and now is on xanax, zoloft and remeron. Was on a higher dose of zoloft then it was decreased. Reports hardest time is in the mornings, mood is low, takes zoloft 50mg and xanax 0.25mg in the morning and Remeron 30mg at night . Sudden Hair loss is biggest stressor as the anxiety has worsened her GI issues, she takes lomotil twice a day. feels guilt, blames self for her hair problems due to not brushing her hair and reports in the morning this causes her stomach problems, feels like her stomach is twisting and feels uncomfortable and lately has been shaky, crying all the times. Self blames for not speaking up when her meds were changed. She worries every day, she’s always anxious. She only feels relaxed at night after taking her remeron and watching tv with her husband at night.
Plan: Since she feels better at night with the Remeron, suggest splitting up the 30mg of Remeron at night and instead take 15mg in the morning and 15mg at night. Psychotherapy encouraged but she’s not ready yet. Also would like to take her off Zoloft and put her back on the paxil but she’s not ready yet for too many changes and wants to do only one thing at a time.
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PRAC_6635_Week5_Assignment2_Part2_Rubric
| PRAC_6635_Week5_Assignment2_Part2_Rubric | ||||||
| Criteria | Ratings | Pts | ||||
| This criterion is linked to a Learning OutcomeComprehensive Psychiatric Evaluation documentation |
|
25 pts | ||||
| Total Points: 25 | ||||||