COMPREHENSIVE PSYCHIATRIC EVALUATION AND PATIENT CASE PRESENTATION

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CC (chief complaint): Different people keep following me and they are always monitoring my every move even when I’m in my house.

HPI: The patient is a 39-year-old Hispanic female diagnosed of Persecutory type of delusion disorder, Patient is married with no kids and her husband works out of state, he comes home every two weeks. She was brought in by her sister-in-law after calling the police many times to complain about someone following her. She also thought she had a monster in her stomach and had stopped eating about three days ago to starve the monster to death. She has also recently been physically aggressive towards others. She broke her TV 4days ago because he felt someone was monitoring her through it.

QUESTION

· 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.

· PRAC_6635_Week9_Assignment2_Part1_Rubric

PRAC_6635_Week9_Assignment2_Part1_Rubric

Criteria

Ratings

Pts

This criterion is linked to a Learning OutcomePhoto 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 OutcomeTime

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 OutcomeDescription 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 OutcomeDescription 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 OutcomeDiscussion 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 OutcomeDiscussion 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 OutcomeDiagnostic 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 OutcomePresentation 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