Posted: October 12th, 2022

Comprehensive Psychiatric Assessment Note and Patient Case Presentation

Task 2: Comprehensive Psychiatric Assessment Note and Patient Case Presentation
Picture Credit score: PexelsPsychiatric notes are a method to mirror in your practicum experiences and join the experiences to the training you achieve out of your weekly Studying Assets. Comprehensive psychiatric analysis notes, corresponding to 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 at your practicum web site, utilizing the Comprehensive Psychiatric Assessment Note Template supplied. You’ll then use this notice to develop and report a case presentation for this affected person.
To PrepareReview this week’s Studying Assets and contemplate the insights they supply about impulse-control and conduct problems.
Choose a affected person for whom you performed psychotherapy for an impulse management or conduct dysfunction over the past 6 weeks. Create a Comprehensive Psychiatric Assessment Note on this affected person utilizing the template supplied within the Studying Assets. There’s additionally a accomplished template supplied as an exemplar and information. All psychiatric analysis notes have to be signed, and every web page have to be initialed by your Preceptor. If you submit your notice, it is best to embody the whole complete analysis notice as a Phrase doc and pdf/photographs of every web page that’s initialed and signed by your Preceptor. You have to submit your notice utilizing SafeAssign. Select a affected person who has obtained psychotherapy for an impulse management or conduct dysfunction within the final 6 weeks. Utilizing the template supplied within the Studying Assets, create a Comprehensive Psychiatric Assessment Note for this affected person. A accomplished template can also be supplied for example and information. Your Preceptor should signal all psychiatric analysis notes and preliminary every web page. When submitting your notice, embody the whole complete analysis notice as a Phrase doc in addition to pdf/photographs of every web page that has been initialed and signed by your Preceptor. You have to use SafeAssign to submit your notice.
Please Note: Digital signatures aren’t accepted. If each recordsdata aren’t obtained by the due date, College will deduct factors per the Walden Grading Coverage.
Then, based mostly in your analysis of this affected person, develop a video presentation of the case. Plan your presentation utilizing the Task rubric and rehearse what you propose to say. Be sure you assessment the Kaltura Media Uploader useful resource within the left-hand navigation of the classroom for Help creating your self-recorded Kaltura video.
Embrace no less than 5 scholarly assets to help your Assessment and diagnostic reasoning.
Guarantee that you’ve got the suitable lighting and gear to report the presentation.
Patient case:
Patient DD is a 19-year-old feminine international pupil from Ghana DX with Main depressive dysfunction (MDD), and Consideration deficit hyperactivity dysfunction (ADHD). Patient experiences her despair is because of a rape incident that occurred three years in the past. Through the consumption session, DD experiences that her motive for coming to the USA is to get educated. She was tearful, and anxious seen quickly tapping toes on the ground. The affected person lives on her campus through the semester and stays together with her married aunt’s household in Baltimore. The affected person’s aunt and husband had been current through the consumption course of. DD’s aunt expressed concern about her niece’s psychological well being and wellbeing after the incident for the reason that Ghanaian justice system did not convict the rapist. The affected person’s aunt additionally experiences that her niece’s refusal to go to her mother and father through the vacation has created a rift between her and DD’s mom, which worsens her despair. Patient additionally said she was managing her ADHD effectively till the rape incident which has triggered regression . The affected person experiences that she experiences nightmares when sleeping at night time and has misplaced curiosity in all of the enjoyable actions that she used to do. The therapist believes that the telehealth-based affected person consumption session is lacking important data because of the affected person’s unwillingness to debate a few of the challenges that she is going through in her life at present. The therapy plan is to make use of CBT to Help DD acknowledge her feeling and develop the best coping technique for tough conditions. Pt she denied suicidal or homicidal ideations, or visible or auditor hallucinations. She denied smoking used, alcohol use, or use of leisure medicine. Pt denied previous medical historical past, and said she has no allergy symptoms to medicine, environmental, latex or meals, and she did obtain the COVID-19 vaccine. Patient denied reproductive historical past, or any household historical past of psychological sickness. Medicine affected person is at present taking is Sertraline (Zoloft) 25mg for despair.

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