PRAC 6635 WEEK 9 ASSIGNMENT 2 PART 1: COMPREHENSIVE PSYCHIATRIC EVALUATION AND PATIENT CASE PRESENTATION, DOCUMENTATION
PRAC 6635 WEEK 9 ASSIGNMENT 2 PART 1: 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.
ORDER A CUSTOMIZED, PLAGIARISM-FREE PRAC 6635 WEEK 9 ASSIGNMENT 2 PART 1: COMPREHENSIVE PSYCHIATRIC EVALUATION AND PATIENT CASE PRESENTATION, DOCUMENTATION HERE
Thanks for stopping by this assessment. We can assist you in completing it and other subsequent ones. Our expert writers will comprehensively review instructions, synthesize external evidence sources, and customize an A-grade paper for YOU!!!
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.
- Ensure that the Turnitin score is low, with a minimal plagiarism match—aim for well under 20%, preferably 15% or less.
Most recent SOAP NOTE ON 01/11/24:
Patient Initials: L. D. 22 yrs M
Subjective note
Pt says that he in not doing well and has been extremely agitated due to his housemate who talks incessantly, interrupts other, and always complains. He says he feels enraged always having to listen to the housemate who he reports purposely behaves in this manner to irritate staff and other residents. Pt does report thoughts of punching his housemate in the head (which e has done in the past) due to his behaviors but has been able to restrain himself; finding this increasingly more difficult. He thinks that having more time with his electronic devices including his laptop will mitigate his interactions with this housemate and relieve his stress. Outside of the home he has been doing well at the day program, enjoyed his holidays, and is looking forward to the upcoming weekend where he will spend time with his step father. His sleep and appetite have been good, no weight changes.
Objective note
Alert and oriented to person, place, and time. Well groomed, attentive, and pleasant. Overall consistent eye contact with occasional downward glance. Able to remain seated, no fidgeting; minimal involuntary movement of fingers at rest noted during AIMS assessment. Mood is good with congruent affects. Speech is regular rate and tone. Thought process is linear and goal oriented. Thought content absent of delusions, hallucinations, or SI/HI.
Assessment note
AIMS score 1 for minimal involuntary ginger movement.
Plan note
Continue current medication regimen with no changes. Will collaborate with group home staff about making adjustments to electronic use allowance as part of behavioral management plan to decrease bouts of agitation and risk for violent outburst.
-Pt will implement deep breathing and anger management strategies when he feels agitated.
-unable to do EKG today but will attempt at next appt
Subjective note
SOAP NOTE PRIOR TO RECENT ON 12/14/2023
Subjective note: Patient seen today for follow up via zoom with behavioral clinical staff and residential supervisor/manager. Per staff regressing, withdrawn, more aggresive and agitated since started at RTR in March and then a month after starting has been hitting other residents, poor impulse control, easily frutrated, yelling, slammng things calling staff names when he doesnt get his way or doesnt get the answer he doesnt like. per staff had been doing better and also likes his therapist but he is not doing the coping exercises he is being given. per staff they have a housemate who recently went on hospice and its possible this may be contributing to his moods. anxiety, racing thoughts or panic attacks, sleep and appetite are the same, denies paranoia or hallucinations, si/hi. Denies Smoking/ETOH/illicit drug use Following up with PCP as needed. No new meds or recent outside hospitalizations. Other than previously stated, the review of systems and organs is noncontributory for constitutional, eyes, ears/nose/mouth/throat, cardiovascular, respiratory, musculoskeletal, neurological, and integumentary issues.
Objective note
appears alert, no apparent distress, . There are no signs of bizarre behaviors, delusions, hallucinations or other indicators of psychosis. Limited to poor insight/judgment , no SI/HI.
Assessment note
cont to struggle with impulse control, and mood regulation, mood is labile, no evidence of acute psychosis or self harm behaviors or Si/HI. Symptoms appear to be behavioral/situational in nature. houemate on hospice may be contributing to this depressed/anxious/agitated state
Plan note
-Increase the Duloxetine to 40mg twice a day and folow up in 3m onths or sooner if needed -Psychotherapy encouraged –Advised to follow up with PCP as scheduled for annual labs including CBC A1C Lipids and EKG -Risks and benefits of medications discussed as well as potential for abuse -Advised to call office with any questions relating to medications or worsening symptoms -Advised to call local crisis/BEST team, or 911 with any thoughts of harm, and to call office with any non-urgent questions or concerns relating to medications and mood. -MassPat Checked/reviewed
Diagnoses
Chronic
- (F84.5) Asperger’s syndrome
- (F43.12) Post-traumatic stress disorder, chronic
- (F39) Unspecified mood [affective] disorder
- (F34.89) Other specified persistent mood disorders
Undefined
- (F41.1) Generalized anxiety disorder
- Medications
- Clonidine HCl (cloNIDine HCl) 0.1 MG Oral Tablet
- Duloxetine HCl (DULoxetine HCl) 40 MG Oral Capsule Delayed Release Particles
- Lumateperone Tosylate (Caplyta) 42 MG Oral Capsule
- Melatonin 10 MG Oral Tablet
- Oxcarbazepine (Oxtellar XR) 600 MG Oral Tablet Extended Release 24 Hour
- Historical medications
- Aripiprazole (Abilify) 10 MG Oral Tablet
- Stop: 04/13/2021
- Aripiprazole (Abilify) 15 MG Oral Tablet
- Stop: 03/02/2021
- Aripiprazole (Abilify) 20 MG Oral Tablet
- Stop: 03/16/2021
- Aripiprazole (Abilify) 5 MG Oral Tablet
- Stop: 04/13/2021
- Cariprazine HCl (Vraylar) 1.5 MG Oral Capsule
- Stop: 04/13/2021
- Cariprazine HCl (Vraylar) 1.5 MG Oral Capsule
- Stop: 02/03/2022
- Cariprazine HCl (Vraylar) 3 MG Oral Capsule
- Stop: 06/10/2021
- Cariprazine HCl (Vraylar) 3 MG Oral Capsule
- Stop: 07/22/2021
- Cariprazine HCl (Vraylar) 4.5 MG Oral Capsule
- Stop: 06/10/2021
- Clonidine HCl (cloNIDine HCl) 0.1 MG Oral Tablet
- Stop: 04/30/2021
- Duloxetine HCl (Cymbalta) 30 MG Oral Capsule Delayed Release Particles
- Stop: 07/27/2023
- Melatonin 10 MG Oral Capsule
- Stop: 02/15/2021
- Oxcarbazepine (OXcarbazepine) 150 MG Oral Tablet
- Stop: 05/13/2021
- Oxcarbazepine (Oxtellar XR) 150 MG Oral Tablet Extended Release 24 Hour
- Stop: 06/24/2021
- Oxcarbazepine (Trileptal) 150 MG Oral Tablet
- Stop: 06/24/2021
- Oxcarbazepine (Trileptal) 300 MG Oral Tablet
- Stop: 06/10/2021
- Sertraline HCl 50 MG Oral Tablet
- Stop: 03/17/2022
- Allergies
- Drug
- Patient has no known drug allergies
- Food
- No food allergies recorded
- Environmental
- No environmental allergies recorded
Social history
Tobacco use
No tobacco use recorded
Initial SOAP NOTE
Per staff 20y/o came to aei respite in october, was the witness to his fathers death of heart attack in 2007 and mom 2017 went to live with dads sister with his sister after mom passed. Aunt patsy reports difficulty setting limits over the years, has episodes pof physical and verbal aggression, closed fist unches self and legs head banging makes a lot of depressive statements, self deprecating, per aunt seems out of touch with rality, obsessed with dungeons and dragons, since coming to AEI on emergency placement due to aunt called police and did not want him to return toher home and was fearful of him. he is currently abilify 10mg once a day, Zoloft 150mg once a day, melatonin 10mg, since he has been with aei staff report he is anxious all the time is easily agitated, they have tried to connect with his previous psych provider but difficulty with communication. He is his own guardian, when agitated may self injure and increased depressive thoughts, episodes of aggression towards his peer who was taunting other housemates and staff and punched the housemate but after wards was very remorseful mad at self saying things “I don’t deserve to live” has had previous hospitalizations, 2018 in Pembroke, 2019 south coast behavioral and 2020 went from toby hospital to community crisis in new Bedford respite for many months. Now at lakevilee home, started new day program and is going through a lot of transisitions.
Reports he is a writer, likes to write fantasy as a hobby. Reports feeling depressed shortly before mom passed away 3-4 years ago. Started seeing a therapist and meds at that time but does not recall what meds he was starting on. Reports feels fine on his current meds which were started about 3-4 years ago. Reports feels” happy and ticked off a bit at times” reports situational, gets ticked off having to deal with certain housemates, his lack of self confidence. He does see a therapist. He denies any med side effects, he is sleeping ok at night, takes melatonin at night, groogy in th morning but ok in the afternoon. He reports a little difficulty with concentration and racing thoughts, depends on the sitation, tries to distract himself with fantasy writing. Does not smoke, but reports punches self in leg or head whenever he is upset. Denies paranoia. Panic attacks once in a while. Increased eye blinking
Plan: genomind testing
Increase the abilify to 15mg
Dx: aspergers, ptsd, anxiety disorder Pcp: still seeing a pediatrician, unclear of lab work,
2 weeks later : Genomind results reviewed today and he is low MTHFR, also
Plan is decrease to 10mg for 3 days then 5mg for 3 days then stop
Start the Vraylar 1.5mg when the abilify is down to 5mg on Saturday
the plan is to decrease the sertraline as well due to poor metabolizer based on his gene test.
follow up in 2 weeks
ORDER A CUSTOMIZED, PLAGIARISM-FREE PRAC 6635 WEEK 9 ASSIGNMENT 2 PART 1: COMPREHENSIVE PSYCHIATRIC EVALUATION AND PATIENT CASE PRESENTATION, DOCUMENTATION HERE
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 | ||||||
PRAC_6635_Week9_Assignment2_Part1_Rubric
| PRAC_6635_Week9_Assignment2_Part1_Rubric | ||||||
| Criteria | Ratings | Pts | ||||
| This criterion is linked to a Learning OutcomePhoto ID display and professional attire |
|
5 pts | ||||
| This criterion is linked to a Learning OutcomeTime |
|
5 pts | ||||
| This criterion is linked to a Learning OutcomeDescription of chief complaint and history of present illness |
|
5 pts | ||||
| This criterion is linked to a Learning OutcomeDescription of past psychiatric, substance use, medical, social, and family history |
|
5 pts | ||||