Assessing patients with symptoms related to the disorders you are

  

Assessing patients with symptoms related to the disorders you are exploring this week pose some particular challenges for which the PMHNP should be prepared. Disruptive, impulse-control, and conduct disorders may involve aggressive outbursts, anger, deceitfulness, and unpredictability. Eliciting the needed interview and history data requires special care, self-control, and deliberateness on the part of the clinician. Several structured or semi-structured clinical interview tools exist for patients and, in the case of minors, for parents as well.

For this Assignment, you will be assigned to a case study by your Instructor and will need to complete a Comprehensive Psychiatric Evaluation on the patient in the case. The case will be related to any of the disruptive, impulse-control, conduct, dissociative, or somatic symptom-related disorders.

To Prepare:

  • Review this week’s Learning Resources      and consider the insights they provide.
  • 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

NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template

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

ROS

· GENERAL: 

· HEENT: 

· SKIN: 

· CARDIOVASCULAR: 

· RESPIRATORY: 

· GASTROINTESTINAL: 

· GENITOURINARY: 

· NEUROLOGICAL: 

· MUSCULOSKELETAL: 

· HEMATOLOGIC: 

· LYMPHATICS: 

· ENDOCRINOLOGIC: 

Physical exam: if applicable

Diagnostic results

Assessment

Mental Status Examination: 

Differential Diagnoses: 

Reflections:

References

To Prepare:

  • Review this week’s Learning Resources and consider the      insights they provide.
  • 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. 
  • you will be assigned to a specific video case study for      this Assignment. View your assigned video case, keeping the requirements      of the documentation 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.

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 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.).

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