Comprehensive Psychiatric Evaluation
Uchechi
ComprehensivePsychiatricEvaluationquestion.docxTraining Title 50
Name: Harold Brown
Gender: male
Age:60 years old
T- 98.8 P- 74 R 18 134/70 Ht 5’10 Wt 170lbs
Background: Has bachelor’s degree in engineering. He dates casually, never married, no children. Has one younger brother. Sleeps 7 hours, appetite good. Denied legal issues; MOCA 28/30 difficulty with attention and delayed recall; ASRS-5 21/24; denied hx of drug use; enjoys one scotch drink on the weekends with a cigar. Allergies Dilaudid; history HTN blood pressure controlled with Cozaar 100mg daily, angina prescribed ASA 81mg po daily, valsartan 80mg daily. Hypertriglyceridemia prescribed fenofibrate 160mg daily, has BPH prescribed tamsulosin 0.4mg po bedtime.
Symptom Media. (Producer). (2017). Training title 50 [Video].
CC (chief complaint): “I work at this large architectural engineering firm.They’ve accelerated the deadlines now and it just puts a lot of pressure on. And I just can’t concentrate. I just can’t seem to be able to do the same job they’re doing.”
HPI: H. G. is a 58-year-old caucasian who came to his appointment with attention and concentration problems. He said he worked for a large architectural engineering firm and they gave them deadlines. This made his life increasingly stressful and affected his ability to concentrate. He told his manager that he was having difficulty with this and it was his manager who made the appointment.
He said he made "silly mistakes" and that those mistakes could have cost the company dearly in repairs or troubleshooting. He mentioned that he had no problem focusing when stress levels were reduced and the company had normal deadlines. He felt like he wasn't “doing his part” and thought his colleagues thought the same. He admitted to having problems with attention and concentration while at school but never received treatment. When studying for exams or doing homework at the library, he gets very distracted by his surroundings. He uses the example of someone who is whispering in a library and has to move to the other side to be able to concentrate. During the chief of his department's lectures, he often doesn't pay attention and ruminates in his head about what needs to be done or his day.
He will also be on a mission and notice something is wrong in another area and he will start looking into that problem whether it is assigned to him or not. He said he wasn't very organized and said: “I’m a bit of a mess...I’m messy, I will forget my shoes, my socks, my phone, my jacket, I can’t find them”. His colleagues gave him a calendar to help him stay organized. His fails to pay his bills until he receives notice that he must pay a fine or receives threatening calls/letters. Sitting seemed difficult for him as he described sitting in a chair as uncomfortable. At school, when he was young, he was reprimanded by his teacher for talking out of turn or in class. He tolerates the occasional consumption of caffeinated drinks, but tries to avoid sugar because it makes him more hyperactive.
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-TR diagnostic criteria for each differential diagnosis and explain what DSM-5-TR 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.).
Rubric
NRNP_6635_Week10_Assignment_Rubric
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NRNP_6635_Week10_Assignment_Rubric |
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Criteria |
Ratings |
Pts |
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This criterion is linked to a Learning OutcomeCreate documentation in the Comprehensive Psychiatric Evaluation Template about the patient you selected. 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 |
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20 pts |
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This criterion is linked to a Learning OutcomeIn 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. |
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20 pts |
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This criterion is linked to a Learning OutcomeIn 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-TR diagnostic criteria for each differential diagnosis and explain what DSM-5-TR 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. |
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25 pts |
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This criterion is linked to a Learning OutcomeReflect on this case. 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!), social determinates of health, 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.). |
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10 pts |
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This criterion is linked to a Learning OutcomeProvide at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support your diagnostics and differential diagnoses. Be sure they are current (no more than 5 years old). |
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15 pts |
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This criterion is linked to a Learning OutcomeWritten Expression and Formatting—Paragraph development and organization: Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused—neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria. |
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5 pts |
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This criterion is linked to a Learning OutcomeWritten Expression and Formatting—English writing standards: Correct grammar, mechanics, and punctuation |
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5 pts |
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Total Points: 100 |
