6635.NonWk4

JtT

Jane, just watch the video of the patient interview. Some extra info is written about him as well. Let me know that the video works ok. Thanks!

· By Day 1 of this week, you will be assigned to a specific video case study for this Assignment. View your assigned video case, keeping the requirements of the documentation template in mind.

· 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.

By Day 7 of Week 4

Complete and submit your Comprehensive Psychiatric Evaluation, including your differential diagnosis and critical-thinking process to formulate 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.).

Patient Info:

You are working as a  PMHNP at a VAMC.  The medical clinic called you to request that you come to see a patient who is currently in for a medical evaluation.   The FNP said that he has “raw wounds” and appears to be a high-risk case.  The FNP was worried if he left with an appointment for the mental health clinic, he may not show up.   She asked that you come connect with him today to help increase his chances of engaging in long term psychiatric care. 

 

During the physical, the patient seemed extremely nervous, stated his fiancé made his appointment telling him he needs to be connected to the VAMC and get the proper care he needs.

 

The patient is 27 years old and has no identified medical problems and his tests today included CBC, Comprehensive Metabolic Panel, and EKG- all  are normal.  He c/o “feeling off”,  having some memory & concentration problems, dizzy/lightheaded spells, and feels exhausted even when he first wakes up from sleeping. 

 

He entered the military just after high school and did three long tours of duty in warzones.  Michael (“everyone calls me “Sergeant”)  separated from active duty in the Army less than a year ago after eight years of service. 

 

He is engaged to be married (no date set) and is currently working as an EMT while studying (last year of BSN).  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 “an abusive drunk.”   He had two older sisters, no bothers.  Siblings are married with kids; one suffers from drug addiction and is in and out of rehab.  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 Michael because of their combat connection.   Mother is alive and well, still “caring for dad.”   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 in a year or two.

 

Video Link

https://video-alexanderstreet-com.ezp.waldenulibrary.org/watch/training-title-21

NRNP/PRAC6635 Comprehensive Psychiatric Evaluation Exemplar

 (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.)

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. This section contains the symptoms that is bringing the patient into your office. 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. 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

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.

© 2020 Walden University

Page 1 of 3

NRNP/PRAC6635 Comprehensive Psychiatric Evaluation Template

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:

Physical exam: if applicable

Diagnostic results:

Assessment

Mental Status Examination:

Differential Diagnoses:

Reflections:

References

© 2020 Walden University

Page 1 of 3

TRANSCRIPT

00:00:15OFF CAMERA Nice to meet you Sergeant. I’m Dr. Schwartz. 

00:00:20SERGEANT Nice to meet you, sir. 

00:00:25OFF CAMERA Can you tell me why you came here today. 

00:00:30SERGEANT My fiance suggested, well demanded that I make an appointment. 

00:00:40OFF CAMERA Why was she concerned? 

00:00:45[Sighs] 

00:00:45SERGEANT Three nights ago, we went with her sister and husband to a county fair. Carnival rides, cotton candy, toss balls at bottles, and win big panda bears, all that silly, old-fashioned stuff, but we were having a good enough time. 

00:01:15OFF CAMERA So all was going well. 

00:01:20SERGEANT Then these fire works go off. No warning. Just big, full sky explosions. 

00:01:30OFF CAMERA Like county fairs do. 

00:01:35SERGEANT I didn’t know they did that. 

00:01:40OFF CAMERA Then what happened? 

00:01:45SERGEANT I took off running. Fast as I could. Tried to find cover. 

00:01:55OFF CAMERA Frightened? 

00:02:00SERGEANT [Sighs] Yeah, scared the… you know, out of me. 

00:02:10OFF CAMERA You didn’t expect the fire works. 

00:02:10SERGEANT These two cops saw me running, I guess they thought I pickpocketed someone, maybe tried to rob a poor country person and I was running away. They took me down, tried to cuff me. 

00:02:30OFF CAMERA Wow. 

00:02:35SERGEANT So I yelled “I’m a combat veteran sir.” Immediately they backed off. They were veterans, understood. 

00:02:50OFF CAMERA They understood that the fireworks sounded like combat fire? 

00:02:55SERGEANT Yeah, exactly sir. God. [Sighs, quivering]. They helped me to my feet, gave me some cold water. I was shaking pretty bad. 

00:03:10OFF CAMERA So they were helpful? 

00:03:15SERGEANT Yeah, absolutely. 

00:03:20OFF CAMERA The explosive sounds took you back in time. 

00:03:25SERGEANT I was… I was right back in the middle of enemy fire, sir. 

00:03:35OFF CAMERA What about other loud noises? 

00:03:40SERGEANT The same. Last week, a car backfired, I jumped behind a

magazine rack. Even a sudden circular saw cutting into wood and I’m… right back there. 

00:04:05OFF CAMERA Are there any smells that set you off? 

00:04:10SERGEANT Yeah, it’s funny you should ask. Yes sir. Diesel fuel. I hate smelling diesel fuel. Chopper smells. And last week, Charlie, my neighbor, was grilling for Jenna’s birthday and he singed some hair on his arm. No injury but… the smell… I had to leave the party pretty fast. 

00:04:55OFF CAMERA What came to mind? 

00:05:00[He pauses, struggling to hold back tears]. 

00:05:10SERGEANT Two of my buddies, they got burned when their Humvee was blown and I smelled their… I’d rather not talk about that, sir. 

00:05:40OFF CAMERA Memories are too strong? 

00:05:45SERGEANT Yeah, way too strong. 

00:05:50[sil.] 

00:05:55OFF CAMERA Do you ever dream about these events? 

00:06:00SERGEANT Every night, sir. Yeah, makes me not want to crawl in bed, not close my eyes. 

00:06:10OFF CAMERA So you have nightmares. You startle easily. Are there any other problems that you’ve noticed? 

00:06:20SERGEANT Like what, sir? 

00:06:25OFF CAMERA Other cues that cause flashbacks or make you anxious? 

00:06:35SERGEANT Traffic. I hate real busy, downtown traffic. Stopping at a traffic

light, with people in front of you and behind you, on both sides of you. I can’t stand that. I start breaking out in a sweat, I start shaking, and I can’t catch my breath. 

00:07:05OFF CAMERA What about traffic is so bad? 

00:07:10SERGEANT Someone could roll an IED under your car. You’re trapped. You can’t get out. 

00:07:25OFF CAMERA That happened overseas? 

00:07:25SERGEANT Yeah. Yeah, to four of my buddies. Blew’em to hell. And I saw it happen to two other vehicles. I didn’t know the guys but… God several times we’d be stuck in traffic, and people were staring at us. And I knew we were going down. Men, women, children. I mean, any of ’em could’a rolled an IED under us. 

00:08:10[He breathes heavily] 

00:08:15OFF CAMERA You look like you’re breathing heavily right now just talking about it. 

00:08:20[Holding back] 

00:08:20SERGEANT Yeah, sorry, sir. I can’t help it. 

00:08:30OFF CAMERA Any other difficulties? 

00:08:40SERGEANT Sometimes my fiance argues with her mother. It used to not matter. Now I can’t handle it. It seems like any negative situation and I just want to crawl into a hole and hide. I’m a wimp, a freaking coward. I don’t, I don’t want to go anywhere. I don’t want to go out to restaurants, or shopping or even to baseball parks. I just stay in my room all day. Afraid to sleep. It’s bad. 

00:09:40OFF CAMERA Have you talked to anyone else about this? 

00:09:45SERGEANT Just you. Just now. I don’t want to remember. 

00:09:55OFF CAMERA You’re very brave for sharing your story with me. I know that must be horribly difficult for you. 

00:10:05SERGEANT Sometimes my stomach muscles get tight. I start getting nauseated. 

00:10:15OFF CAMERA Your body is reacting normally to bad events that you’ve experienced. 

00:10:20SERGEANT I don’t want to be a whiner. 

00:10:25OFF CAMERA You know, talking can actually help your brain to heal. Talking takes it out of the feeling mode and puts it into the thinking mode so that you don’t hear those same stories over and over again. So in a way you feel like you’re in control. We could work on this together. 

00:10:55SERGEANT I would like that, sir. Very much. 

00:11:00OFF CAMERA Good. Let’s get you scheduled for an appointment then. 

00:11:05SERGEANT Thank you, sir. Sometimes I feel like it’s never going to end. You know I thought I was going to crazy. Sometimes my mind just sinks back into itself, like I can’t see or hear or move. It’s like I’m numb all over. Lose track of time. 

00:11:40SymptomMedia Visual Learning for Behavioral Health www.symptommedia.com 

00:11:40END TRANSCRIPT