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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 Name: Ms. Natalie Crew Gender: female Age:17 years old T 97.4 P-82 R-1 20 128/84 Ht 5’2” Wt 192lbs Background: Recently started an accelerated high school business program in Chicago, Illinois after growing up and living in New Orleans her whole life. Grew up with both parents and four brothers. Currently lives in on a specialty high school campus dormitory. Currently a full-time student and works part time in the local coffee shop. Not married, currently single. She has no previous psychiatric history; takes no medications. There is history of depression, denied substance use history for her or family. No legal hx NKDA

BEGIN TRANSCRIPT:

00:00:00 [sil.] 00:00:15 OFF CAMERA Why did your mom feel you should come in and talk with me today? 00:00:20 MRS HOUSTON She was worried. Mom says I get moody this time of year, every year. I don't know. Maybe. 00:00:40 OFF CAMERA How are you feeling, when? 00:00:45 PATIENT Not great. 00:00:45 OFF CAMERA What's not great? 00:00:50 PATIENT Huh. Just down. I'm not doing so well. 00:01:05 OFF CAMERA How's school? 00:01:05 PATIENT Ok. 00:01:10 OFF CAMERA Just ok? 00:01:15 PATIENT Yeah. I left the program at school. I mean I did and... I'm not doing so well. 00:01:25 OFF CAMERA Are the courses difficult? 00:01:30 [sil.] 00:01:35 PATIENT I understand everything. The teachers are getting to be a bit of a pain. The classes aren't lustrous (Sighs). I'm in this special business program, where you have to come up with a mock company. I just... I just can't seem to get it done. That, and all my other projects. I'm already late on two of them. 00:02:25 OFF CAMERA Are you having difficult concentrating? 00:02:30 PATIENT Yeah. I'll read the headlines in the newspaper and like, five seconds later, I can't remember what I read. And my classes, when I leave the room, I don't what we were learning about. 00:02:55 OFF CAMERA Are you having any irregular sleeping or eating patterns? 00:03:05 PATIENT (Sighs) I've gained ten pounds. Umm... I've slept through five of my classes this month if that answers your question. 00:03:20 OFF CAMERA Have you been able to make any friends? 00:03:25 PATIENT [Shrugs] Yeah. Almost immediately. The people are a lot of fun. 00:03:30 OFF CAMERA What do you do with them? 00:03:35 PATIENT Lately, not so much of anything. 00:03:45 OFF CAMERA What happened? 00:03:50 PATIENT Well, it was a blast when I arrived in August. I made friends almost immediately. We went to concerts and shows, we hung out. And we had a lot of fun. 00:04:15 OFF CAMERA You don't do any of that now? 00:04:20 PATIENT They kind of annoy me a little bit. I mean nothing I can't get over. They got really dull. They suddenly started playing board games... and then, things also got busy and with the weather, I don't want to go outside. 00:04:45 OFF CAMERA Do you particularly dislike the cold weather? 00:04:50 PATIENT It's not like I have a burning passionate hatred for the cold. I've always fretted fall and winter. I'm a summer girl. I like the beach and convertibles. And now... 00:05:10 OFF CAMERA You can't do any of that. 00:05:10 PATIENT No. In fact you can't do anything at all. 00:05:15 OFF CAMERA Can you tell me what it is you dislike about this time of the year? 00:05:25 PATIENT It's dark. And grey. And miserable. The whole city changes, it's not the same city that I loved in August. September was good. It was beautiful. Sunny, crisp days and, the leaves changing at the end of the month and then it just started getting worse and worse. Even... the snow is grey and black. I didn't know snow got like that, city snow. I thought snow was white and beautiful. But city snow isn't like that. Everything is grey. It's miserable. 00:06:30 [sil.] 00:06:35 SymptomMedia Visual Learning for Behavioral Health www.symptommedia.com 00:06:35

END TRANSCRIPT

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.

RESOURCES

Be sure to review the Learning Resources before completing this activity. Click the weekly resources link to access the resources.

TO PREPARE:

· Review this week’s Learning Resources. Consider the insights they provide about assessing and diagnosing mood disorders. · Download the Comprehensive Psychiatric Evaluation Template, which you will use to complete this Assignment. Also review the Comprehensive Psychiatric Evaluation Exemplar to see an example of a completed evaluation document. · By Day 1 of this week, select a specific video case study to use for this Assignment from the Video Case Selections choices in the Learning Resources. View your assigned video case and review the additional data for the case in the “Case History Reports” document, keeping the requirements of the evaluation 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 3

Complete and submit your Comprehensive Psychiatric Evaluation, 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-TR 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.). Resources · American Psychiatric Association. (2022). Bipolar and related disorders. In Diagnostic and statistical manual of mental disorders Links to an external site. (5th ed., text rev.). https://go.openathens.net/redirector/waldenu.edu?url= https://dsm.psychiatryonline.org/doi/full/10.1176/appi.books.9780890425787.x03_Bipolar_and_Related_Disorders · American Psychiatric Association. (2022). Depressive disorders. In Diagnostic and statistical manual of mental disorders Links to an external site. (5th ed., text rev.). https://go.openathens.net/redirector/waldenu.edu?url=https://dsm.psychiatryonline.org/doi/full/10.1176/appi.books.9780890425787.x04_Depressive_Disorders · Boland, R. & Verduin, M. L. & Ruiz, P. (2022). Kaplan & Sadock’s synopsis of psychiatry (12th ed.). Wolters Kluwer. · Chapter 2 -only sections 2.9, “Depressive Disorders and Suicide in Children and Adolescents” 2.10 Early-Onset Bipolar Disorder”, and 2.11 “Disruptive Mood Dysregulation Disorder” · Chapter 6 “Bipolar Disorders” · Chapter 7 “Depressive Disorders” Select one of the following videos to use for your Assignment this week. Then, access the document “Case History Reports” and review the additional data about the patient in the specific video number you selected. · Symptom Media. (Producer). (2016). Training title 2 Links to an external site. [Video]. https://go.openathens.net/redirector/waldenu.edu?url=https://video.alexanderstreet.com/watch/training-title-2 · Symptom Media. (Producer). (2016). Training title 8Links to an external site. [Video]. https://go.openathens.net/redirector/waldenu.edu?url=https://video.alexanderstreet.com/watch/training-title-8 · Symptom Media. (Producer). (2017). Training title 18Links to an external site. [Video]. https://go.openathens.net/redirector/waldenu.edu?url=https://video.alexanderstreet.com/watch/training-title-18 · Symptom Media. (Producer). (2016). Training title 28 Links to an external site. [Video]. https://go.openathens.net/redirector/waldenu.edu?url=https://video.alexanderstreet.com/watch/training-title-28 · Symptom Media. (Producer). (2016). Training title 38Links to an external site. [Video]. https://go.openathens.net/redirector/waldenu.edu?url=https://video.alexanderstreet.com/watch/training-title-38 · Symptom Media. (Producer). (2016). Training title 43Links to an external site. [Video]. https://go.openathens.net/redirector/waldenu.edu?url=https://video.alexanderstreet.com/watch/training-title-43 · Symptom Media. (Producer). (2018). Training title 118Links to an external site. [Video]. https://go.openathens.net/redirector/waldenu.edu?url=https://video.alexanderstreet.com/watch/training-title-118 · Symptom Media. (Producer). (2018). Training title 144Links to an external site. [Video]. https://go.openathens.net/redirector/waldenu.edu?url=https://video.alexanderstreet.com/watch/training-title-144 · Symptom Media. (Producer). (2018). Training title 150Links to an external site. [Video]. https://go.openathens.net/redirector/waldenu.edu?url=https://video.alexanderstreet.com/watch/training-title-150 image1.jpeg

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