Chat with us, powered by LiveChat Psychiatric notes are a way to reflect on your practicum experiences and connect the experiences to the learning you gain from your weekly Learning Resources. Comprehensive psy - Wridemy Essaydoers

Psychiatric notes are a way to reflect on your practicum experiences and connect the experiences to the learning you gain from your weekly Learning Resources. Comprehensive psy

 

Psychiatric notes are a way to reflect on your practicum experiences and connect the experiences to the learning you gain from your weekly Learning Resources. Comprehensive psychiatric evaluation notes, such as the ones required in this practicum course, are often used in clinical settings to document patient care.

For this Assignment, you will document information about a patient that you examined at your practicum site, using the Comprehensive Psychiatric Evaluation Note Template provided. You will then use this note to develop and record a case presentation for this patient. 

Case study3

Chief complaint “she drives me insane, all she does in nag me”

HPI: Patient is a married caucasion male referred to therapy by his wife. The patient's wife has

recently threatened divorce, claiming his anger is out of control. He has been married for 7 years.

Patient states that his relationship was great for the first 2 years. Over the last 5 years, he has

gotten increasingly inpatient and agitated with his wife. Him and his wife have been living

separately for the last 6 months. The patient started having angry violent outbursts 6 months ago,

almost daily. After the outburst, the patient leaves and stays in his brother's guest house. When he

would return home the next morning, his wife would confront his behavior and disappearance,

and the outburst would start over. The patient reports that the family has gone through 5 cell

phones this year because he throws them on the ground and stomps on them during the outburst.

He also screams with such intensity that he is unintelligible. Upon leaving the house, he

slammed the sliding glass door so hard that the glass shattered. Since the marital issues, his wife

has been maintaining their live/work business solely while raising their son who is 18 months.

He spends most hours of the day at his brother's guest house unable to resolve the longstanding

conflict with his wife. He denies emotional/behavioral problems prior to 5 years ago.

Past Psychiatric History:

● Psychotherapy or Previous Psychiatric Diagnosis: None

Substance Current Use and History: Infrequent social drinker, 2-3 beers. Heavy use of

caffeine, 6+ cups daily. Smokes “dabs” daily, 1 gram per day. Denies using hallucinogens,

opioids, sedatives, hypnotics, anxiolytics, nicotine or stimulants.

Family Psychiatric/Substance Use History: None provided

Psychosocial History: Patient was born and raised in Reno, NV by his biological parents. He

has one older brother. After the passing of both his parents, he and his brother inherited the house

and resided there together through adulthood. His brother moved out after his wife moved in 7

years ago. He describes his childhood as “great”. He is a highschool graduate, taking normal

classes. After highschool he attended a trade school and started working as an electrician. He

gave up his trade after meeting his wife and opened up an art/jewelry gallery on their property.

No religious preference. He has no criminal background, but police have been sent to the

residence on multiple occasions due to disturbances on the property. Warnings have been issued.

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Instruction.:

Assignment 2: Comprehensive Psychiatric Evaluation Note and Patient Case Presentation

Psychiatric notes are a way to reflect on your practicum experiences and connect the experiences to the learning you gain from your weekly Learning Resources. Comprehensive psychiatric evaluation notes, such as the ones required in this practicum course, are often used in clinical settings to document patient care.

For this Assignment, you will document information about a patient that you examined at your practicum site, using the Comprehensive Psychiatric Evaluation Note Template provided. You will then use this note to develop and record a case presentation for this patient.

To Prepare

Review this week's Learning Resources and consider the insights they provide about impulse-control and conduct disorders.

Select a patient for whom you conducted psychotherapy for an impulse control or conduct disorder during the last 6 weeks. Create a Comprehensive Psychiatric Evaluation Note on this patient using the template provided in the Learning Resources. There is also a completed template provided as an exemplar and guide. All psychiatric evaluation notes must be signed, and each page must be initialed by your Preceptor. When you submit your note, you should include the complete comprehensive evaluation note as a Word document and pdf/images of each page that is initialed and signed by your Preceptor. You must submit your note using SafeAssign.

Then, based on your evaluation of this patient, develop a video presentation of the case. Plan your presentation using the Assignment rubric and rehearse what you plan to say. Be sure to review the Kaltura Media Uploader resource in the left-hand navigation of the classroom for help creating your self-recorded Kaltura video.

Include at least five scholarly resources to support your assessment and diagnostic reasoning.

The Assignment

Record yourself presenting the complex case for your clinical patient.

In your presentation:

Dress professionally and present yourself in a professional manner.

Present the full complex case study. Be succinct in your presentation, and do not exceed 8 minutes. Include subjective and objective data; assessment from most recent mental status exam; current psychiatric diagnosis including differentials that were ruled out; current psychotherapeutic plan (include one health promotion activity and one patient education strategy you provided); and patient progress toward treatment goals.

Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What was 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 in order of highest to lowest priority and explain why you chose them. What was your primary diagnosis and why? Describe how your primary diagnosis aligns with DSM-5-TR diagnostic criteria and is supported by the patient’s symptoms.

Plan: Describe your treatment modality and your plan for psychotherapy. Explain the principles of psychotherapy that underline your chosen treatment plan to support your rationale for the chosen psychotherapy framework. What were your follow-up plan and parameters? What referrals would you make or recommend as a result of this psychotherapy session?

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.

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NRNP/PRAC 6645 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:

(include psychiatric ROS rule out)

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:

Objective:

Diagnostic results:

Assessment:

Mental Status Examination:

Differential Diagnoses:

Reflections:

Case Formulation and Treatment Plan

Reference

© 2021 Walden University Page 1 of 3

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