PRAC 6665 Assignment 2 WEEK 3: Comprehensive Psychiatric Evaluation and Patient Case Presentation
Walden University PRAC 6665 Assignment 2 WEEK 3: Comprehensive Psychiatric Evaluation and Patient Case Presentation-Step-By-Step Guide
This guide will demonstrate how to complete the Walden University PRAC 6665 Assignment 2 WEEK 3: Comprehensive Psychiatric Evaluation and Patient Case Presentation assignment based on general principles of academic writing. Here, we will show you the A, B, Cs of completing an academic paper, irrespective of the instructions. After guiding you through what to do, the guide will leave one or two sample essays at the end to highlight the various sections discussed below.
How to Research and Prepare for PRAC 6665 Assignment 2 WEEK 3: Comprehensive Psychiatric Evaluation and Patient Case Presentation
Whether one passes or fails an academic assignment such as the Walden University PRAC 6665 Assignment 2 WEEK 3: Comprehensive Psychiatric Evaluation and Patient Case Presentation depends on the preparation done beforehand. The first thing to do once you receive an assignment is to quickly skim through the requirements. Once that is done, start going through the instructions one by one to clearly understand what the instructor wants. The most important thing here is to understand the required format—whether it is APA, MLA, Chicago, etc.
After understanding the requirements of the paper, the next phase is to gather relevant materials. The first place to start the research process is the weekly resources. Go through the resources provided in the instructions to determine which ones fit the assignment. After reviewing the provided resources, use the university library to search for additional resources. After gathering sufficient and necessary resources, you are now ready to start drafting your paper.
How to Write the Introduction for PRAC 6665 Assignment 2 WEEK 3: Comprehensive Psychiatric Evaluation and Patient Case Presentation
The introduction for the Walden University PRAC 6665 Assignment 2 WEEK 3: Comprehensive Psychiatric Evaluation and Patient Case Presentation is where you tell the instructor what your paper will encompass. In three to four statements, highlight the important points that will form the basis of your paper. Here, you can include statistics to show the importance of the topic you will be discussing. At the end of the introduction, write a clear purpose statement outlining what exactly will be contained in the paper. This statement will start with “The purpose of this paper…” and then proceed to outline the various sections of the instructions.
How to Write the Body for PRAC 6665 Assignment 2 WEEK 3: Comprehensive Psychiatric Evaluation and Patient Case Presentation
After the introduction, move into the main part of the PRAC 6665 Assignment 2 WEEK 3: Comprehensive Psychiatric Evaluation and Patient Case Presentation assignment, which is the body. Given that the paper you will be writing is not experimental, the way you organize the headings and subheadings of your paper is critically important. In some cases, you might have to use more subheadings to properly organize the assignment. The organization will depend on the rubric provided. Carefully examine the rubric, as it will contain all the detailed requirements of the assignment. Sometimes, the rubric will have information that the normal instructions lack.
Another important factor to consider at this point is how to do citations. In-text citations are fundamental as they support the arguments and points you make in the paper. At this point, the resources gathered at the beginning will come in handy. Integrating the ideas of the authors with your own will ensure that you produce a comprehensive paper. Also, follow the given citation format. In most cases, APA 7 is the preferred format for nursing assignments.
How to Write the Conclusion for PRAC 6665 Assignment 2 WEEK 3: Comprehensive Psychiatric Evaluation and Patient Case Presentation
After completing the main sections, write the conclusion of your paper. The conclusion is a summary of the main points you made in your paper. However, you need to rewrite the points and not simply copy and paste them. By restating the points from each subheading, you will provide a nuanced overview of the assignment to the reader.
How to Format the References List for PRAC 6665 Assignment 2 WEEK 3: Comprehensive Psychiatric Evaluation and Patient Case Presentation
The very last part of your paper involves listing the sources used in your paper. These sources should be listed in alphabetical order and double-spaced. Additionally, use a hanging indent for each source that appears in this list. Lastly, only the sources cited within the body of the paper should appear here.
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Sample Answer for PRAC 6665 Assignment 2 WEEK 3: Comprehensive Psychiatric Evaluation and Patient Case Presentation
Subjective:
CC (chief complaint): “I have been experiencing suicidal thoughts for the last three weeks.”
HPI: A.A. is a 35-year-old male that came to the clinic today with complaints of suicidal thoughts for the last three weeks. The client reported a series of events leading to the symptoms. They included having a depressed mood for almost all day and feeling hopeless. He also reported feelings of lack of energy, changes in appetite, and being socially isolated. He was worried that his interest in pleasure had declined significantly. A.A. also reported experiencing insomnia for the last two months and finding it hard to concentrate on things. He denied any suicidal plan or attempt. The symptoms could not be attributed to substance abuse, medication, or medical condition. The symptoms had affected his ability to engage in his social and occupational roles.
Substance Current Use: The client does not have a history of drug and substance abuse.
Medical History: No history of chronic illnesses or admission.
- Current Medications: None
- Allergies: Allergic to latex
- Reproductive Hx: Married, has two children. He does not have a history of sexually transmitted infections or infertility. He does not have a history of increased urinary urgency and frequency.
ROS:
GENERAL: There is no evident weight loss, fever, chills, weakness, or fatigue.
HEENT: Eyes: The patient denies visual loss, blurred vision, double vision, or yellow sclera. Ears, Nose, Throat: The patient denies hearing loss, sneezing, congestion, runny nose, or sore throat.
SKIN: The client denies rash or itching.
CARDIOVASCULAR: The client denies chest pain, chest pressure, or chest discomfort. No palpitations or edema.
RESPIRATORY: The client denies shortness of breath, cough, or sputum.
GASTROINTESTINAL: The patient denies anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.
GENITOURINARY: The patient denies burning on urination and a history of sexually transmitted infections
NEUROLOGICAL: The patient denies headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: The client denies muscle or joint pain, joint rigidity, tenders, and difficulty in movement. He also denies fractures.
HEMATOLOGIC: The patient denies anemia, bleeding, or bruising.
LYMPHATICS: The patient denies enlarged nodes. No history of splenectomy.
PSYCHIATRIC: The patient denies any history of depression or anxiety.
ENDOCRINOLOGIC: The patient denies sweating, cold, or heat intolerance reports. No polyuria or polydipsia.
ALLERGIES: The patient is allergic to latex.
Objective:
Diagnostic results: Some diagnostic investigations were ordered to determine the cause of the client’s problem accurately. Laboratory investigations, including complete blood count and thyroid function tests, were performed. Complete blood work aimed at determining any other conditions contributing to the worsening of the client’s symptoms. Thyroid function tests were performed to rule out thyroid disorders such as hyperthyroidism, which may produce symptoms similar to depression. Radiological investigations, including an MRI scan, were ordered to rule out pathologies such as brain tumors, which may contribute to the client’s symptoms (Alshawwa et al., 2019). The results were unremarkable, leading to a potential diagnosis of a mental health problem.
Assessment:
Mental Status Examination: The client appeared dressed appropriately for the occasion. His orientation to self, others, time, and events were intact. His speech had a normal rate, speed, and volume. He maintained normal eye contact during the assessment. The self-reported mood of the client was depressed. He denied illusions, delusions, and hallucinations. He reported suicidal thoughts without plans or intent. The thought process was future-oriented.
Diagnostic Impression:
Major Depression: Major depression is the primary diagnosis for the client. He presents with symptoms that align with depression, as stated in DSM-5. According to DSM-5, patients suffering from depression present with complaints that include depressed mood for most days, almost every day, diminished interest and pleasure, social isolation, and feelings of guilt. They also experience suicidal thoughts, attempts, or plans alongside having trouble making decisions. Patients also report increased irritability, sleeping patterns, and appetite changes (Kraus et al., 2019; Pradier et al., 2021). A.A. has most of the above symptoms, making depression the primary diagnosis.
Insomnia: The secondary differential diagnosis that should be considered for the client is insomnia. According to DSM-5, patients with insomnia report a decline in the quality and quantity of sleep. Poor sleep quality alters their normal routines and their ability to undertake their social, academic, and occupational roles (Albrecht et al., 2019). Unlike A.A., patients with insomnia do not experience depressed moods, lack of interest and pleasure, and suicidal thoughts.
Bipolar Disorder: The third secondary diagnosis that may be considered for the client is bipolar disorder. Patients with bipolar disorder experience cycles of mania and hypomania. The symptoms of elevated mood alternate with those of depressed mood (Perrotta, 2019). A.A. did not report such cycling in mood experiences, ruling out bipolar disorder as a possibility in his case.
Reflections: I believe that I did my best in examining this client. I utilized professional knowledge and skills in obtaining accurate data that led to the diagnosis. I also utilized evidence-based data to make informed decisions about the potential mental health problem for the client. I also incorporated collaboration in patients’ assessment and development of diagnosis and the plan of care. I would use the Patient Health Questionnaire-9 (PHQ-9) to determine the severity of depressive symptoms should I have the opportunity to assess the patient again. The assessment data will guide the determination of the appropriate dosing for the client’s medications.
Case Formulation and Treatment Plan: A.A. has been diagnosed with major depression. He has been initiated on PO Zoloft 25 mg daily for the next month. He has also been enrolled in group psychotherapy sessions. He has been scheduled for a follow-up visit after four weeks to determine his response to treatment.
References
Albrecht, J. S., Wickwire, E. M., Vadlamani, A., Scharf, S. M., & Tom, S. E. (2019). Trends in Insomnia Diagnosis and Treatment Among Medicare Beneficiaries, 2006–2013. The American Journal of Geriatric Psychiatry, 27(3), 301–309. https://doi.org/10.1016/j.jagp.2018.10.017
Alshawwa, I. A., Elkahlout, M., El-Mashharawi, H. Q., & Abu-Naser, S. S. (2019). An Expert System for Depression Diagnosis.
Kraus, C., Kadriu, B., Lanzenberger, R., Zarate Jr., C. A., & Kasper, S. (2019). Prognosis and improved outcomes in major depression: A review. Translational Psychiatry, 9(1), 1–17. https://doi.org/10.1038/s41398-019-0460-3
Perrotta, G. (2019). Bipolar disorder: Definition, differential diagnosis, clinical contexts and therapeutic approaches. J Neuroscience and Neurological Surgery, 5.
Pradier, M. F., Hughes, M. C., McCoy, T. H., Barroilhet, S. A., Doshi-Velez, F., & Perlis, R. H. (2021). Predicting change in diagnosis from major depression to bipolar disorder after antidepressant initiation. Neuropsychopharmacology, 46(2), 455–461. https://doi.org/10.1038/s41386-020-00838-x
Sample Answer 2 for PRAC 6665 Assignment 2 WEEK 3: Comprehensive Psychiatric Evaluation and Patient Case Presentation
Subjective:
CC (chief complaint): “My motherhood experience is overwhelming
HPI: K.B. is a 21-year-old female patient who visited the facility after being referred to the facility by her primary physician. She reports giving birth to her first child some weeks prior. She indicates that she has been experiencing persistent symptoms such as sadness, lower energy, and sleeping complications. She is mostly tearful as she feels overwhelmed by the need to take care of her child. She expresses thoughts of inadequacy as a mother and doubts if she would be a good mother. In addition, she also reports that her sleep patterns have changed since the baby cries a lot at night, and her partner is living in another town; hence, she cannot help with the baby. She also reports worries about her financial status since she doesn’t have a stable job, and she is concerned about whether she will be able to have enough food for the baby and herself.
Past Psychiatric History:
- General Statement: The patient’s first experience with treatment was when she was admitted to the hospital for food poisoning at the age of 15.
- Caregivers (if applicable): She mainly lives alone; hence, no immediate caregiver
- Hospitalizations: The patient has no recent major hospitalization, except the hospital admission at 15 years old when she had food poisoning.
- Medication trials: The patient has not previously tried any psychotropic medications
- Psychotherapy or Previous Psychiatric Diagnosis: No records of previous psychiatric diagnosis or psychotherapy.
Substance Current Use and History: The patient reports using alcohol occasionally. She drinks at most two glasses during occasions such as parties and celebrations. She denies the use of any other illicit substance, caffeine or nicotine.
Family Psychiatric/Substance Use History: The patient’s parents are both alive. While the mother has a history of PTSD, the father has a history of major depression, which were both well-managed
Psychosocial History: The patient was born and raised in California. She has one elder brother and a teenage younger sister. The patient currently lives alone in an apartment. She has a boyfriend, and they are planning to get married soon. She gave birth to her first child a few weeks ago. The patient is a high school graduate and recently registered for a college diploma, studying hospitality. She has no current or past legal issues or history.
Medical History:
- Current Medications: The patient is not using any medications apart from the over-the-counter sleeping pills that she bought to enable her sleep.
- Allergies: No known allergies
- Reproductive Hx: The patient’s last menstrual date was around ten months ago; she is not pregnant, as she just recently gave birth. The patient is in a heterosexual relationship and engages in vaginal sex.
Objective:
ROS
General: The patient denies headache or chills. She reports fatigue
Psychiatric: She reports feelings of sadness, tearfulness, and difficulty concentrating.
Diagnostic results: Complete blood count and thyroid function tests to help rule out any underlying medical condition that could be contributing to depressive symptoms
Assessment:
Mental Status Examination: The patient is a 21-year-old female who came to the facility for a psychiatric review. The patient is appropriately dressed and well-groomed. She is also alert and oriented. However, she looks fatigued. She looks sad and displays difficulty concentrating. She is in a depressed mood. The affect is congruent with mood but she displays tearfulness. The patient’s memory is intact, although she finds it hard to concentrate. She also has a consistent thought process. She denies suicidal thoughts.
Differential Diagnoses:
- Postpartum depression: This is a type of mood disorder known to affect women after childbirth. A patient with these symptoms may present with exhaustion, anxiety, and extreme sadness, which affects their ability to take care of themselves and the newborn (Liu et al.,2022). This patient experienced various symptoms, such as sadness, low energy, sleep disturbances, and feelings of inadequacy as a mother. Therefore, this is the primary diagnosis.
- Adjustment disorder: This is a condition that occurs when a patient responds to a substantial level of distress (Liang et al.,2021). The patient has financial worries and also lacks sufficient support from her partner. However, the persistence and severity of the symptoms are more indicative of the previous diagnosis.
- Anxiety disorder: The patient reports anxiety and worries over her financial status and the ability to take care of her child. Therefore, anxiety disorder is one of the differential diagnoses (Park & Kim, 2020). However, while anxiety may contribute to her overall distress, it appears to be secondary to the stressors and depressive symptoms that have come due to her new status as a new mother.
Reflections: I agree with the preceptor’s assessment and diagnostic impression of the patient. For example, the primary diagnosis of postpartum depression is based on the DSM-V criteria, which makes it more accurate. I learned various things from this case. One of them is the importance of conducting a thorough assessment to help gain deeper insight into the patient’s current condition, overall functioning, and symptoms. I also learned that it is vital to consider environmental and social factors when assessing patients for mental health complications (Handy et al.,2022). What I would do differently is consult the patient’s obstetrician/Gynecologist to help with information regarding any medical complications noted during childbirth for a better understanding of the patient’s health status. One of the ethical/legal considerations is informed consent and patient autonomy. It is important that the patient adequately understands her condition, treatment, and management options available, and associated benefits and risks. It is also important to focus on confidentiality and privacy and ensure that discussions and interventions undertaken are accomplished in a confidential and private manner to uphold her dignity (Blease et al.,2021). Among the social determinants of health relevant to this case is social support. The patient’s partner lives in another town, so she lacks the social support she needs. As such, it is important to connect the patient to support groups for new mothers and community resources and help organize practical assistance with household responsibilities and childcare.
Case Formulation and Treatment Plan:
It is vital to have an appropriate case formulation and treatment plan for this patient. Diagnostics studies will include CBC and thyroid function tests, which can help in ruling out any other condition that could be causing the depressive symptoms. The Edinburg Postnatal Depression Scale (EPDS) should also be administered to help in the assessment of the postpartum depression symptoms severity. As part of the treatment plan, the patient should start individual or group cognitive behavioral therapy sessions. This strategy will help the patient identify and challenge negative thought patterns and behaviors (Milgrom et al.,2021). The same approach can be applied to the case of other differential diagnoses. The patient needs to be educated regarding relaxation techniques to help manage her stress and depressive symptoms more appropriately. In terms of the disposition of the patient, she will get outpatient treatment with regular therapy sessions. She will also be connected with community resources for new mothers. The patient should come for a follow-up after two weeks following regular therapy sessions.
I confirm the patient used for this assignment is a patient that was seen and managed by the student at their Meditrek approved clinical site during this quarter course of learning.
References
Blease, C. R., O’Neill, S. F., Torous, J., DesRoches, C. M., & Hagglund, M. (2021). Patient access to mental health notes: motivating evidence-informed ethical guidelines. The Journal of Nervous and Mental Disease, 209(4), 265-269. Doi: 10.1097/NMD.0000000000001303
Handy, A. B., Greenfield, S. F., Yonkers, K. A., & Payne, L. A. (2022). Psychiatric symptoms across the menstrual cycle in adult women: a comprehensive review. Harvard Review of Psychiatry, 30(2), 100-117. Doi: 10.1097/HRP.0000000000000329
Liang, L., Ben-Ezra, M., Chan, E. W., Liu, H., Lavenda, O., & Hou, W. K. (2021). Psychometric evaluation of the Adjustment Disorder New Module-20 (ADNM-20): A multi-study analysis. Journal of Anxiety Disorders, 81, 102406. https://doi.org/10.1016/j.janxdis.2021.102406
Liu, X., Wang, S., & Wang, G. (2022). Prevalence and risk factors of postpartum depression in women: A systematic review and meta‐analysis. Journal of Clinical Nursing, 31(19-20), 2665-2677. https://doi.org/10.1111/jocn.16121
Milgrom, J., Danaher, B. G., Seeley, J. R., Holt, C. J., Holt, C., Ericksen, J., … & Gemmill, A. W. (2021). Internet and face-to-face cognitive behavioral therapy for postnatal depression compared with treatment as usual: randomized controlled trial of MumMoodBooster. Journal of Medical Internet Research, 23(12), e17185. doi: https://doi.org/10.2196/17185
Park, S. C., & Kim, Y. K. (2020). Anxiety Disorders in the DSM-5: changes, controversies, and future directions. Anxiety Disorders: Rethinking and Understanding Recent Discoveries, 187-196. Doi: 10.1007/978-981-32-9705-0_12