Comprehensive Psychiatric Evaluation And Patient Case Presentation

For this Assignment, you will document information about a patient that you examined during the last 3 weeks, using the Comprehensive Psychiatric Evaluation Template provided. You will then use this note to develop and record a case presentation for this patient. Be sure to incorporate any feedback you received on your Week 3 and Week 6 case presentations into this final presentation for the course.

HISTORY: Ms. Okonofua is a 55-year-old woman. Her chief complaint is, “I have been having

difficulty sleeping and anxiety. These has been going on for years. My anxiety and jitteriness get

worse when I drink caffeine. I usually don’t sleep for more than 5 hours. I cannot stay asleep. There

are times that I will not sleep for 3 days and I will be very irritable, unable to concentrate or function

the next day. “.

Anxiety Symptoms:

Ms. Okonofua exhibits symptoms of anxiety. Her anxiety symptoms have been present for

years.

Ms. Okonofua describes the following anxiety symptoms:

*Chest pain or discomfort when under stress.

*Diarrhea

*Increase in Heart Rate

*Sensations of muscular tension

Insomina symptoms

*Sleep disturbance, she has difficulty staying asleep. she has difficulty falling asleep.

*Trembling or shaking

*Excessive worrying

Ms. Okonofua’s symptoms are occurring daily. She reports previous episodes of anxiety

symptoms.

Severity is estimated to be medium based on Ms. Okonofua’s risk of morbidity without

treatment and her description of interference with functioning.

Cardiovascular:

*Hypertension

Eyes:

*Corrective Lenses are used: (Glasses)

Review of all other systems reviewed were negative.

PAST PSYCHIATRIC HISTORY:

Okonofua, Deborah

9/30/1964DOB:

6/9/2020

ID:

page 2 of 5

1000010715483

Complete Evaluation: Continued

medicaid ID:

Room No.

Psychiatric Hospitalization:

Ms. Okonofua has never been psychiatrically hospitalized.

Outpatient Treatment:

Has never received outpatient mental health treatment.

Suicidal/Self Injurious:

Ms. Okonofua has no history of suicidal or self injurious behavior.

Psychotropic Medication History: lexapro (caused weight gain), ambien, benadryl

Prior Psychiatric Disorder:

She has a history of anxiety symptoms.

SOCIAL/DEVELOPMENTAL HISTORY:

Ms. Okonofua is a 55 year old woman. Born and raised in Nigeria, migrated to USA years ago.

Married, has 4 children (1 set of twins), a nurse practitioner.

Abuse/Neglect:

There is no known history of physical, sexual or emotional abuse.

There is no known history of physical, medical, or emotional neglect.

Criminal Justice History:

Ms. Okonofua has never been arrested or incarcerated, has no history of violence, and is

not currently under any kind of court supervision.

Coping Strengths:

Spiritual:

*Religious Beliefs are a Strength

*Spiritual Beliefs are a Strength. “Pastor’s wife”.

Criminal Justice History:

Ms. Okonofua has never been arrested or incarcerated, has no history of violence, and is

not currently under any kind of court supervision.

Substance Abuse:

Ms. Okonofua denies any history of substance abuse.

FAMILY HISTORY:

Mother known to have anxiety.

Ms. Okonofua’s family psychiatric history is otherwise negative. There is no other history of

psychiatric disorders, psychiatric treatment or hospitalization, suicidal behaviors or substance

abuse in closely related family members.

Okonofua, Deborah

9/30/1964DOB:

Assignment 2: Comprehensive Psychiatric Evaluation and Patient Case Presentation

Select a patient that you examined during the last 3 weeks who presented with a disorder for which you have not already conducted an evaluation in Weeks 3 or 6. (For instance, if you selected a patient with OCD in Week 6, you must choose a patient with another type of disorder for this week.) Conduct a Comprehensive Psychiatric Evaluation on this patient using the template provided in the Learning Resources. There is also a completed exemplar document in the Learning Resources so that you can see an example of the types of information a completed evaluation document should contain. All psychiatric evaluations must be signed, and each page must be initialed by your Preceptor. When you submit your document, you should include the complete Comprehensive Psychiatric Evaluation as a Word document, as well as a PDF/images of each page that is initialed and signed by your Preceptor. You must submit your document using SafeAssign. Please Note: Electronic signatures are not accepted. If both files are not received by the due date, Faculty will deduct points per the Walden Late Policies.

Then, based on your evaluation of this patient, develop a video case presentation that includes chief complaint; history of present illness; any pertinent past psychiatric, substance use, medical, social, family history; most recent mental status exam; and current psychiatric diagnosis including differentials that were ruled out.

Include at least five (5) scholarly resources to support your assessment and diagnostic reasoning.

Assignment

Record yourself presenting the complex case for your clinical patient. In your presentation:

Present the full case. Include chief complaint; history of present illness; any pertinent past psychiatric, substance use, medical, social, family history; most recent mental status exam; and current psychiatric diagnosis including differentials that were ruled out.

Report normal diagnostic results as the name of the test and “normal” (rather than specific value). Abnormal results should be reported as a specific value.

Be succinct in your presentation, and do not exceed 8 minutes. Address the following:

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?

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ADDITIONAL INSTRUCTIONS FOR THE CLASS

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2. Fill in your paper’s requirements in the “PAPER INFORMATION” section and the system will calculate your order price/cost.
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Discussion Questions (DQ)

Initial responses to the DQ should address all components of the questions asked, including a minimum of one scholarly source, and be at least 250 words. Successful responses are substantive (i.e., add something new to the discussion, engage others in the discussion, well-developed idea) and include at least one scholarly source. One or two-sentence responses, simple statements of agreement or “good post,” and responses that are off-topic will not count as substantive. Substantive responses should be at least 150 words. I encourage you to incorporate the readings from the week (as applicable) into your responses.

Weekly Participation

Your initial responses to the mandatory DQ do not count toward participation and are graded separately. In addition to the DQ responses, you must post at least one reply to peers (or me) on three separate days, for a total of three replies. Participation posts do not require a scholarly source/citation (unless you cite someone else’s work). Part of your weekly participation includes viewing the weekly announcement and attesting to watching it in the comments. These announcements are made to ensure you understand everything that is due during the week.

APA Format and Writing Quality

Familiarize yourself with the APA format and practice using it correctly. It is used for most writing assignments for your degree. Visit the Writing Center in the Student Success Center, under the Resources tab in Loud-cloud for APA paper templates, citation examples, tips, etc. Points will be deducted for poor use of APA format or absence of APA format (if required). Cite all sources of information! When in doubt, cite the source. Paraphrasing also requires a citation. I highly recommend using the APA Publication Manual, 6th edition.

Use of Direct Quotes

I discourage over-utilization of direct quotes in DQs and assignments at the Master’s level and deduct points accordingly. As Masters’ level students, it is important that you be able to critically analyze and interpret information from journal articles and other resources. Simply restating someone else’s words does not demonstrate an understanding of the content or critical analysis of the content. It is best to paraphrase content and cite your source.

LopesWrite Policy

For assignments that need to be submitted to Lopes Write, please be sure you have received your report and Similarity Index (SI) percentage BEFORE you do a “final submit” to me. Once you have received your report, please review it. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Take the extra few minutes to review instead of getting counted off for these mistakes. Review your similarities. Did you forget to cite something? Did you not paraphrase well enough? Is your paper made up of someone else’s thoughts more than your own? Visit the Writing Center in the Student Success Center, under the Resources tab in Loud-cloud for tips on improving your paper and SI score.

Late Policy

The university’s policy on late assignments is a 10% penalty PER DAY LATE. This also applies to late DQ replies. Please communicate with me if you anticipate having to submit an assignment late. I am happy to be flexible, with advance notice. We may be able to work out an extension based on extenuating circumstances. If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect. I do not accept assignments that are two or more weeks late unless we have worked out an extension. As per policy, no assignments are accepted after the last day of class. Any assignment submitted after midnight on the last day of class will not be accepted for grading.

Communication

Communication is so very important. There are multiple ways to communicate with me: Questions to Instructor Forum: This is a great place to ask course content or assignment questions. If you have a question, there is a good chance one of your peers does as well. This is a public forum for the class. Individual Forum: This is a private forum to ask me questions or send me messages. This will be checked at least once every 24 hours.

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Comprehensive Psychiatric Evaluation And Patient Case Presentation