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 weeks 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:
Reproductive Hx:
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 weeks 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 patients 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.).
