PRAC 6635 Week 9 Assignment: Comprehensive Psychiatric Evaluation and Patient Case Presentation
PRAC 6635 Week 9 Assignment: Comprehensive Psychiatric Evaluation and Patient Case Presentation
Bipolar Disorder
Name: E.D.
Age: 35 years
Diagnosis: Bipolar disorder
S: E.D. is a 35-year-old patient who came to the facility for her follow-up visit. She was diagnosed with bipolar disorder a month ago and started treatment. The diagnosis was reached after she presented to the clinic with complaints of an unusual pattern of depressed and expansive mood. She reported that she has been having periods of depressed and elevated moods for the last six months. The symptoms have been worsening over time. The last period of a depressive mood was a week before the client’s initial visit to the facility. E.D. reported that she experiences symptoms such as feeling low, lacking interest and pleasure, being fatigued, and sleeping too much during the period of a depressed mood. She noted that she finds it difficult to engage in her social and occupational activities, as evidenced by her lack of energy to provide for her family’s needs and complete the assigned tasks on time. She experiences symptoms such as racing thoughts, too much drinking and reckless sexual activities, insomnia, and being talkative during periods of expansive mood. E.D. noted that the symptoms are significantly distressing. She denied substance use or abuse, medication use, and medical conditions. She was diagnosed with bipolar disorder and started treatment.
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O: E.D. was dressed appropriately for the occasion. She was alert and oriented to herself, time, and events. She maintained normal eye contact and responded appropriately to questions during the assessment. She denied a depressed mood, anxiety, or increased energy levels. She denied illusions, delusions, and hallucinations. She also denied suicidal thoughts, plans, and attempts.
A: The patient reports improvement in symptoms of bipolar disorder.
P: E.D. was advised to continue with the prescribed medications and individual psychotherapy. She was scheduled for a follow-up visit after four weeks.
Comprehensive Psychiatric Evaluation 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 Evaluation 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.
Resources
Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.
WEEKLY RESOURCE
Learning Resources
Required Readings
Carlat, D. J. (2017). The psychiatric interview (4th ed.). Wolters Kluwer.
Chapter 31, “Assessing Personality Disorders”
Chapter 32, “How to Educate Your Patient”
HSoft Corporation. (2020). Meditrek: Home
Links to an external site.. https://edu.meditrek.com/Default.html
Note: Use this website to log into Meditrek to report your clinical hours and patient encounters.
Document: Comprehensive Psychiatric Evaluation Template
Download Comprehensive Psychiatric Evaluation Template (Word document)
Document: Comprehensive Psychiatric Evaluation Exemplar
Download Comprehensive Psychiatric Evaluation Exemplar (Word document)
Recommended
American Psychiatric Association. (2022). Sexual dysfunctions
Links to an external site.. In Diagnostic and statistical manual of mental disorders (5th ed., text rev.).
American Psychiatric Association. (2022). Personality disorders
Links to an external site.. In Diagnostic and statistical manual of mental disorders (5th ed., text rev.).
American Psychiatric Association. (2022). Paraphilic disorders
Links to an external site.. In Diagnostic and statistical manual of mental disorders (5th ed., text rev.).
Boland, R. Verdiun, M. L. & Ruiz, P. (2022). Kaplan & Sadock’s synopsis of psychiatry (12th ed.). Wolters Kluwer.
Walden University. (2020). College of Nursing practicum manual: Master of science in nursing (MSN) and post-master’s certificate programs
Links to an external site.. https://academicguides.waldenu.edu/fieldexperience/son/formsanddocuments
Walden University Field Experience. (2020a). Field experience: College of Nursing
Links to an external site..  https://academicguides.waldenu.edu/fieldexperience/son/home
Walden University Field Experience. (2020b). Student practicum resources: NP student orientation
Links to an external site.. https://academicguides.waldenu.edu/StudentPracticum/NP_StudentOrientation
To Prepare
Review this week’s Learning Resources and consider the insights they provide. Also review the Kaltura Media resource in the Classroom Support Center area (accessed via the Help button).
Select a patient that you examined during the last 3 weeks who presented with a disorder for which you have not already conducted an evaluation 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 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. All psychiatric evaluations must be signed by your Preceptor. When you submit your document, you should include the complete Comprehensive Psychiatric Evaluation as a Word document, and the completed assignment signed by your Preceptor. You must submit your document using Turn It In. 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 evaluation 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.
Do not sit and read your written evaluation! The video portion of the assignment is a simulation to demonstrate your ability to succinctly and effectively present a complex case to a colleague for a case consultation. The written portion of this assignment is a simulation for you to demonstrate to the faculty your ability to document the complex case as you would in an electronic medical record. The written portion of the assignment will be used as a guide for faculty to review your video to determine if you are omitting pertinent information or including non-essential information during your case staffing consultation video.
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 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.
By Day 7
Submit your Video Case Presentation.
Note: In Week 9: Assignment 2, Part 2 you will submit two (2) files for the Comprehensive Psychiatric Evaluation, including a Word document and scanned PDF/images of the completed assignment signed by your Preceptor.
submission information
1. Click on Start Assignment near the top of the page.
2. Next, click Text Entry and then click the Embed Kaltura Media button.
3. Select your recorded video under My Media.
4. Check the box for the End-User License Agreement and select Submit Assignment for review.
Rubric
PRAC_6635_Week9_Assignment2_Part1_Rubric
PRAC_6635_Week9_Assignment2_Part1_Rubric
Criteria Ratings Pts
This criterion is linked to a Learning Outcome Photo ID display and professional attire
5 to >0.0 pts
Excellent
Photo ID is displayed. The student is dressed professionally.
0 pts
Fair
0 pts
Good
0 pts
Poor
Photo ID is not displayed. Student must remedy this before grade is posted. The student is not dressed professionally.
5 pts
This criterion is linked to a Learning Outcome Time
5 to >0.0 pts
Excellent
The video does not exceed the 8-minute time limit.
0 pts
Fair
0 pts
Good
0 pts
Poor
The video exceeds the 8-minute time limit. (Note: Information presented after the 8 minutes will not be evaluated for grade inclusion.)
5 pts
This criterion is linked to a Learning Outcome Description of chief complaint and history of present illness
5 to >4.0 pts
Excellent
The student provides an accurate, clear, and complete description of the chief complaint and history of present illness.
4 to >3.0 pts
Good
The student provides an accurate description of the chief complaint and history of present illness.
3 to >1.0 pts
Fair
The student provides a vague, inaccurate, or incomplete description of the chief complaint and history of present illness, or description is missing.
1 to >0 pts
Poor
The student provides a completely inaccurate, or incomplete description of the chief complaint and history of present illness, or the description is missing.
5 pts
This criterion is linked to a Learning Outcome Description of past psychiatric, substance use, medical, social, and family history
5 to >4.0 pts
Excellent
The student provides an accurate, clear, and complete description of past psychiatric, substance use, medical, social, and family history.
4 to >3.0 pts
Good
The student provides an accurate description of past psychiatric, substance use, medical, social, and family history.
3 to >1.0 pts
Fair
The student provides a vague, inaccurate, or incomplete description of psychiatric, substance use, medical, social, and family history, or description is missing.
1 to >0 pts
Poor
The student provides a completely inaccurate, or incomplete description of psychiatric, substance use, medical, social, and family history, or description is missing.
5 pts
This criterion is linked to a Learning Outcome Discussion of most recent mental status exam and observations made during interview and review of systems
15 to >13.0 pts
Excellent
The student provides an accurate, clear, and complete discussion of results from most recent mental status exam and observations made during interview and review of systems.
13 to >11.0 pts
Good
The student provides an accurate discussion of results from most recent mental status exam and observations made during interview and review of systems.
11 to >10.0 pts
Fair
The student provides a vague, inaccurate, or incomplete discussion of results from most recent mental status exam and observations made during interview and review of systems.
10 to >0 pts
Poor
All or most of the discussion is inaccurate or missing.
15 pts
This criterion is linked to a Learning Outcome Discussion of diagnostics with results
10 to >8.0 pts
Excellent
The student provides an accurate, clear, and complete discussion of diagnostics with results.
8 to >7.0 pts
Good
The student provides an accurate discussion of diagnostics with results.
7 to >6.0 pts
Fair
The student provides a vague, inaccurate, or incomplete discussion of diagnostics with results.
6 to >0 pts
Poor
All or most of the discussion is inaccurate or missing.
10 pts
This criterion is linked to a Learning Outcome Diagnostic Impression with three (3) differential diagnoses Reflection on this case
25 to >22.0 pts
Excellent
The student provides an accurate, clear, and complete diagnostic impression with three (3) differentials. … Reflections are thorough, thoughtful, and demonstrate critical thinking. …Reflections contain all 3 elements from the assignment directions.
22 to >19.0 pts
Good
The student provides an accurate diagnostic impression with three (3) differentials…. Reflections demonstrate critical thinking…. Reflections contain 2 of the elements from the assignment directions.
19 to >17.0 pts
Fair
The student provides a vague, inaccurate, less than 3, or incomplete diagnostic impression with differentials…. Reflections are somewhat general or do not demonstrate critical thinking…. Reflections contain 1 of the required elements from the assignment directions.
17 to >0 pts
Poor
All or most of the discussion is inaccurate or missing. No diagnostic impression and less than 2 differential diagnoses…. Reflections are incomplete, inaccurate, or missing. … There are no Reflections elements from the assignment directions.
25 pts
This criterion is linked to a Learning Outcome Presentation style
5 to >4.0 pts
Excellent
Presentation style is exceptionally clear, professional, and focused.
4 to >3.0 pts
Good
Presentation style is clear, professional, and focused.
3 to >2.0 pts
Fair
Presentation style is mostly clear, professional, and focused
2 to >0 pts
Poor
Presentation style is unclear, unprofessional, and/or unfocused.
5 pts
Total Points: 75