Posted: April 14th, 2022

Comprehensive Psychiatric Evaluation And Patient Case Presentation

Chief compliant (CC). His chief grievance is, “depress and nervousness as a consequence of divorce”.

HISTORY: Patient is a 44 years outdated Caucasian male affected person with historical past of hyperlipemia, Alcohol use dysfunction,

hashish use, tobacco use, generalized nervousness dysfunction, Main depressive dysfunction that’s

managed on lamotrigine, hydroxyzine, Propanolol previously. He’s on Lexopro 10mg day by day and

Clonazepam zero.5mg BID. He does CBT with Mid Atlantic therapist. He endorsed tolerability and

adherence.

Signs/Habits Patient reported that his divorced was finalized in 2019 to his spouse of 14 years. Patient endorsed

working as engineer at Verizon and has one other diploma in psychology. Patient endorse improved

low vitality, lack of motivation, anhedonia, poor urge for food, poor sleep, irritability, nervousness, isolative,

however denies hopelessness, hopelessness, and responsible emotions. Patient endorsed improved nervous,

uncontrol worries, irritability, worrying about various things, anxious and concern of impending doom.

Patient endorsed improved racing ideas, temper swings, irritable, impulsivity, spending spree,

grandiosity, and dangerous behaviors. Patient denies mania, hypomania, PTSD and psychosis. Patient

denies historical past of abuse or trauma. Patent reported sleeps eight hours nightly with out of nightmares.

Patient with historical past AUD, reported his final alcohol use to be November 2020. Patient smoked

1PPD cigarette smoker for 30 years endorsed vaping now. He final Hashish use was yesterday

August 13, 2021. He denies different leisure medication. He denies audio / visible hallucination. Patient

denies loss of life want, he vehemently suicidal and homicidal ideation, intent or plain and verbally

contracted security. Patient reported atheist religion, his mates, and household, his canine (Amber) as his

protecting issue.

7/17/1977DOB:

PAST PSYCHIATRIC HISTORY:

Dependancy/Use Historical past: Alcohol use dysfunction,

Tobacco use,

Psychotropic Remedy Historical past:

lamotrigine, hydroxyzine, Propanolol previously.

He’s on Lexapro 10mg day by day and Clonazepam zero.5mg BID.

Outpatient Remedy:

He does CBT with Mid Atlantic therapist.

SOCIAL/DEVELOPMENTAL HISTORY:

Mr. Rice is a divorced 44 12 months outdated man. He’s Not Hispanic or Latino. He’s a Atheist. His

emergency contact is his Elizabeth Rice

Growth Historical past:

Particulars of Mr. Rice’s developmental historical past aren’t accessible right now.

FAMILY HISTORY:

Father has melancholy, Mind tumor and TBI.

Mom had GAD.

Sister was Despair and nervousness

MEDICAL HISTORY:

hyperlipemia

EXAM: Mr. Rice seems unhappy trying, He displays speech that’s regular in fee, quantity, and

articulation and is coherent and spontaneous. Language abilities are intact. Indicators of reasonable

melancholy are current. Indicators of reasonable melancholy are current. Have an effect on is acceptable, full

vary, and congruent with temper. There aren’t any obvious indicators of hallucinations, delusions, weird

behaviors, or different indicators of psychotic course of. Associations are intact, considering is logical, and

thought content material seems applicable. Suicidal concepts or intentions are denied. Homicidal concepts or

intentions are denied. Perception into issues seems regular. Judgment seems intact. There are

indicators of tension.

Task 2: Comprehensive Psychiatric Evaluation and Patient Case Presentation

Comprehensive psychiatric evaluations are a method to replicate in your practicum experiences and join the experiences to the educational you acquire out of your weekly Studying Sources. Comprehensive notes, resembling those required on this practicum course, are sometimes utilized in scientific settings to doc affected person care.

For this Task, you’ll doc details about a affected person that you simply examined over the past 7 weeks, utilizing the Comprehensive Psychiatric Evaluation Template supplied. You’ll then use this notice to develop and document a case presentation for this affected person.

To Put together

Choose a affected person that you simply examined over the past 7 weeks. Overview prior sources on the dysfunction this affected person has.

It’s endorsed that you simply use the Kaltura Private Seize device to document and add your project.

Conduct a Comprehensive Psychiatric Evaluation on this affected person utilizing the template supplied within the Studying Sources. All psychiatric evaluations have to be signed, and every web page have to be initialed by your Preceptor. While you submit your doc, it is best to embody the whole Comprehensive Psychiatric Evaluation as a Phrase doc, in addition to a PDF/photos of every web page that’s initialed and signed by your Preceptor. You should submit your doc utilizing SafeAssign. Please Be aware: Digital signatures aren’t accepted. If each information aren’t obtained by the due date, School will deduct factors per the Walden Late Insurance policies.

Develop a video case presentation, primarily based in your progress notice of this affected person, that features chief grievance; historical past of current sickness; any pertinent previous psychiatric, substance use, medical, social, household historical past; most up-to-date psychological standing examination; and present psychiatric prognosis, together with differentials that had been dominated out.

Embrace a minimum of 5 (5) scholarly sources to assist your evaluation and diagnostic reasoning.

Guarantee that you’ve got the suitable lighting and gear to document the presentation.

Task

Current the total case. Embrace chief grievance; historical past of current sickness; any pertinent previous psychiatric, substance use, medical, social, household historical past; most up-to-date psychological standing examination; and present psychiatric prognosis, together with differentials that had been dominated out.

Report regular diagnostic outcomes because the title of the check and “regular” (slightly than particular worth). Irregular outcomes needs to be reported as a particular worth.

Be succinct in your presentation, and don’t exceed eight minutes. Handle the next:

Subjective: What particulars did the affected person present relating to their private and medical historical past? What are their signs of concern? How lengthy have they been experiencing them, and what’s the severity? How are their signs impacting their functioning?

Goal: What observations did you make through the interview and assessment of programs?

Evaluation: What had been your differential diagnoses? Present a minimal of three (three) potential diagnoses. Listing them from highest to lowest precedence. What was your main prognosis, and why?

Reflection notes: What would you do in a different way in an identical affected person analysis?

———-

Complainant in chief (CC). His major grievance is “divorce-related melancholy and nervousness.”

HISTORY: The affected person is a 44-year-old Caucasian male with a historical past of hyperlipemia, alcohol use dysfunction, and diabetes.

Hashish use, tobacco use, generalized nervousness dysfunction, and main depressive dysfunction are all examples of psychological sicknesses.

Beforehand, I used to be on lamotrigine, hydroxyzine, and propanolol. He takes Lexopro 10mg day-after-day.

Clonazepam zero.5mg twice a day. He receives CBT from a therapist within the Mid Atlantic area. He advocated for tolerance and

adherence.

Signs/Habits The affected person reported that his 14-year divorce from his spouse was finalized in 2019. Patient approval

Working as an engineer at Verizon, he additionally has a level in psychology. Patient approval has improved.

Anhedonia, low vitality, lack of motivation, anhedonia, poor urge for food, poor sleep, irritability, nervousness, isolative,

however denies emotions of hopelessness, hopelessness, and guilt Patient

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