* Please review the complete instructions
* Use the attached document to complete the assignment
* Review the exemplar as a guide to the assignment
* Attached is the transcript of the video needed to complete the assignment.
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
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
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
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.
Assignment Instructions:
· Use the Comprehensive Psychiatric Evaluation Template (Attached) to complete this Assignment.
· Review the Comprehensive Psychiatric Evaluation Exemplar (Attached) to see an example of a completed evaluation document.
· Select a specific video case study to use for this Assignment from the Video Case Selections choices in the Learning Resources. Video # 28 (See the transcript).
· 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 (attached), 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.).
· Minimums 5 references
Assignment: Assessing and Diagnosing Patients
with
Mood Disorders
Accurately diagnosing depr
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 patie
__ https://go.openathens.net/redirector/waldenu.edu?url=https://video.alexanderstreet.com/watch/training-title-28
____________________________________________________________________________
00:00:00
BEGIN TRANSCRIPT:
00:00:15
OFF CAMERA Mrs. Carson? Tell me why you’ve come to see me today.
00:00:20
MRS. CARSON I’m… [Shrugs] Wound up. Lost my temper.
00:00:25
OFF CAMERA What sorts of things make you lose your temper?
00:00:25
MRS. CARSON Oh… lots of things. The kids. They get on my nerves.
00:00:35
OFF CAMERA When does that happen?
00:00:40
MRS. CARSON Playing the television too loud. Take Shawn for instance? He spilled sugar all over the counter last night when my husband was out.
00:00:50
OFF CAMERA And then what happened?
00:00:55
MRS. CARSON I lost my temper. I pushed him down. Not hard… he wasn’t hurt, just cried a little. Maybe…
00:01:10
OFF CAMERA Maybe what?
00:01:15
MRS. CARSON I was just thinking.
00:01:15
OFF CAMERA What were you thinking?
00:01:20
MRS. CARSON Maybe I should go away.
00:01:20
OFF CAMERA Go away?
00:01:25
MRS. CARSON Yeah. Like I shouldn’t be here.
00:01:25
OFF CAMERA Have you thought about killing yourself?
00:01:30
MRS. CARSON [nods] Some.
00:01:35
OFF CAMERA How would you do it?
00:01:40
MRS. CARSON Driving into something. Drink a whole bunch, then drive… then make it look like an accident.
00:01:50
OFF CAMERA Have you tried that? Or made plans?
00:01:50
MRS. CARSON [Shakes head]. Naw. It was just a thought I had once or twice. Nothing for real. Everyone has those kinds of thoughts at some time, you know?
00:02:05
OFF CAMERA I’m not so sure about that. How long have you been thinking about driving into something?
00:02:15
MRS. CARSON Three months or so, I guess.
00:02:15
OFF CAMERA What else was going on three months ago?
00:02:25
MRS. CARSON I was up for a promotion, didn’t get it. [Shrugs]. But lots of guys didn’t make it either.
00:02:35
OFF CAMERA So you didn’t get the promotion?
00:02:35
MRS. CARSON I should have had that promotion. I would… I would have been a supervisor at the whole office. But my supervisor said others who were better, younger.
00:02:55
OFF CAMERA How did that make you feel about yourself?
00:03:00
MRS. CARSON Not so hot. My husband and children deserve better. Even the job I’m doing is at risk, in jeopardy.
00:03:15
OFF CAMERA How so?
00:03:20
MRS. CARSON I forget things. Five years of a perfect work record and my supervisor asked me is something wrong. [Shrugs]. So much for a promotion.
00:03:40
OFF CAMERA Has worrying about him interfered with your sleep?
00:03:45
MRS. CARSON [nods] It goes round and round in my head like… I can’t get to sleep. Finally after a few hours I… I drop off.
00:04:00
OFF CAMERA And what time do you wake up?
00:04:00
MRS. CARSON Three, maybe four in the morning.
00:04:05
OFF CAMERA Do you go back to sleep then?
00:04:05
MRS. CARSON I can’t go back to sleep. If I take a sti
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