Assign DSM-5
Assign DSM-5
The Assignment
- Assign DSM-5 and ICD-10 codes to services based upon the patient case scenario.
Then, in 1–2 pages address the following: You may add your narrative answers to these questions to the bottom of the case scenario document and submit them altogether as one document.
- Explain what pertinent information, generally, is required in documentation to support DSM-5 and ICD-10 coding.
- Explain what pertinent documentation is missing from the case scenario, and what other information would be helpful to narrow your coding and billing options.
- Pathways Mental Health
Psychiatric Patient Evaluation
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Instructions |
Use the following case template to complete Week 2 Assignment 1. On page 5, assign DSM-5 and ICD-10 codes to the services documented. You will add your narrative answers to the assignment questions to the bottom of this template and submit altogether as one document. | |
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Identifying Information |
Identification was verified by stating of their name and date of birth. Time spent for evaluation: 0900am-0957am |
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Chief Complaint |
“My other provider retired. I don’t think I’m doing so well.” |
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HPI |
25 yo Russian female evaluated for psychiatric evaluation referred from her retiring practitioner for PTSD, ADHD, Stimulant Use Disorder, in remission. She is currently prescribed fluoxetine 20mg po daily for PTSD, atomoxetine 80mg po daily for ADHD. Today, client denied symptoms of depression, denied anergia, anhedonia, amotivation, no anxiety, denied frequent worry, reports feeling restlessness, no reported panic symptoms, no reported obsessive/compulsive behaviors. Client denies active SI/HI ideations, plans or intent. There is no evidence of psychosis or delusional thinking. Client denied past episodes of hypomania, hyperactivity, erratic/excessive spending, involvement in dangerous activities, self-inflated ego, grandiosity, or promiscuity. Client reports increased irritability and easily frustrated, loses things easily, makes mistakes, hard time focusing and concentrating, affecting her job. Has low frustration tolerance, sleeping 5–6 hrs/24hrs reports nightmares of previous rape, isolates, fearful to go outside, has missed several days of work, appetite decreased. She has somatic concerns with GI upset and headaches. Client denied any current binging/purging behaviors, denied withholding food from self or engaging in anorexic behaviors. No self-mutilation behaviors. |
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Diagnostic Screening Results |
Screen of symptoms in the past 2 weeks: PHQ 9 = 0 with symptoms rated as no difficulty in functioning Interpretation of Total Score Total Score Depression Severity 1-4 Minimal depression 5-9 Mild depression 10-14 Moderate depression 15-19 Moderately severe depression 20-27 Severe depression GAD 7 = 2 with symptoms rated as no difficulty in functioning Interpreting the Total Score: Total Score Interpretation ≥10 Possible diagnosis of GAD; confirm by further evaluation 5 Mild Anxiety 10 Moderate anxiety 15 Severe anxiety MDQ screen negative PCL-5 Screen 32 |
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Past Psychiatric and Substance Use Treatment |
Entered mental health system when she was age 19 after raped by a stranger during a house burglary. Previous Psychiatric Hospitalizations: denied Previous Detox/Residential treatments: one for abuse of stimulants and cocaine in 2015 Previous psychotropic medication trials: sertraline (became suicidal), trazodone (worsened nightmares), bupropion (became suicidal), Adderall (began abusing) Previous mental health diagnosis per client/medical record: GAD, Unspecified Trauma, PTSD, Stimulant use disorder, ADHD confirmed by school records |
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Substance Use History |
Have you used/abused any of the following (include frequency/amt/last use): Substance Y/N Frequency/Last Use Tobacco products Y ½ ETOH Y last drink 2 weeks ago, reports drinks 1-2 times monthly one drink socially Cannabis N Cocaine Y last use 2015 Prescription stimulants Y last use 2015 Methamphetamine N Inhalants N Sedative/sleeping pills N Hallucinogens N Street Opioids N Prescription opioids N Other: specify (spice, K2, bath salts, etc.) Y reports one-time ecstasy use in 2015 Any history of substance related: Blackouts: + Tremors: – DUI: – D/T’s: – Seizures: – Longest sobriety reported since 2015—stayed sober maintaining sponsor, sober friends, and meetings |
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Psychosocial History |
Client was raised by adoptive parents since age 6; from Russian orphanage. She has unknown siblings. She is single; has no children. Employed at local tanning bed salon Education: High School Diploma Denied current legal issues. |
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Suicide / Homicide Risk Assessment |
RISK FACTORS FOR SUICIDE: Suicidal Ideas or plans – no Suicide gestures in past – no Psychiatric diagnosis – yes Physical Illness (chronic, medical) – no Childhood trauma – yes Cognition not intact – no Support system – yes Unemployment – no Stressful life events – yes Physical abuse – yes Sexual abuse – yes Family history of suicide – unknown Family history of mental illness – unknown Hopelessness – no Gender – female Marital status – single White race Access to means Substance abuse – in remission PROTECTIVE FACTORS FOR SUICIDE: Absence of psychosis – yes Access to adequate health care – yes Advice & help seeking – yes Resourcefulness/Survival skills – yes Children – no Sense of responsibility – yes Pregnancy – no; last menses one week ago, has Norplant Spirituality – yes Life satisfaction – “fair amount” Positive coping skills – yes Positive social support – yes Positive therapeutic relationship – yes Future oriented – yes Suicide Inquiry: Denies active suicidal ideations, intentions, or plans. Denies recent self-harm behavior. Talks futuristically. Denied history of suicidal/homicidal ideation/gestures; denied history of self-mutilation behaviors Global Suicide Risk Assessment: The client is found to be at low risk of suicide or violence, however, risk of lethality increased under context of drugs/alcohol. No required SAFETY PLAN related to low risk |
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Mental Status Examination |
She is a 25 yo Russian female who looks her stated age. She is cooperative with examiner. She is neatly groomed and clean, dressed appropriately. There is mild psychomotor restlessness. Her speech is clear, coherent, normal in volume and tone, has strong cultural accent. Her thought process is ruminative. There is no evidence of looseness of association or flight of ideas. Her mood is anxious, mildly irritable, and her affect appropriate to her mood. She was smiling at times in an appropriate manner. She denies any auditory or visual hallucinations. There is no evidence of any delusional thinking. She denies any current suicidal or homicidal ideation. Cognitively, She is alert and oriented to all spheres. Her recent and remote memory is intact. Her concentration is fair. Her insight is good. |
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Clinical Impression |
Client is a 25 years Russian female who presents with history of treatment for PTSD, ADHD, Stimulant use Disorder, in remission. Moods are anxious and irritable. She has ongoing reported symptoms of re-experiencing, avoidance, and hyperarousal of her past trauma experiences; ongoing subsyndromal symptoms related to her past ADHD diagnosis and exacerbated by her PTSD diagnosis. She denied vegetative symptoms of depression, no evident mania/hypomania, no psychosis, denied anxiety symptoms. Denied current cravings for drugs/alcohol, exhibits no withdrawal symptoms, has somatic concerns of GI upset and headaches. At the time of disposition, the client adamantly denies SI/HI ideations, plans or intent and has the ability to determine right from wrong, and can anticipate the potential consequences of behaviors and actions. She is a low risk for self-harm based on her current clinical presentation and her risk and protective factors. |
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Diagnostic Impression |
[Student to provide DSM-5 and ICD-10 coding] Double click inside this text box to add/edit text. Delete placeholder text when you add your answers. |
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Treatment Plan |
Medication: Increase fluoxetine 40mg po daily for PTSD #30 1 RF Continue with atomoxetine 80mg po daily for ADHD. #30 1 RF Instructed to call and report any adverse reactions. Future Plan: monitor for decrease re-experiencing, hyperarousal, and avoidance symptoms; monitor for improved concentration, less mistakes, less forgetful Education: Risks and benefits of medications are discussed including non-treatment. Potential side effects of medications discussed. Verbal informed consent obtained. Not to drive or operate dangerous machinery if feeling sedated. Not to stop medication abruptly without discussing with providers. Discussed risks of mixing medications with OTC drugs, herbal, alcohol/illegal drugs. Instructed to avoid this practice. Praised and Encouraged ongoing abstinence. Maintain support system, sponsors, and meetings. Discussed how drugs/ETOH affects mental health, physical health, sleep architecture. Patient was educated about therapy and services of the MHC including emergent care. Referral was sent via email to therapy team for PET treatment. Patient has emergency numbers: Emergency Services 911, the national Crisis Line 800-273-TALK, the MHC Crisis Clinic. Patient was instructed to go to nearest ER or call 911 if they become actively suicidal and/or homicidal. Time allowed for questions and answers provided. Provided supportive listening. Patient appeared to understand discussion and appears to have capacity for decision making via verbal conversation. RTC in 30 days Follow up with PCP for GI upset and headaches, reviewed PCP history and physical dated one week ago and include lab results Patient is amenable with this plan and agrees to follow treatment regimen as discussed. |
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Narrative Answers
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[In 1-2 pages, address the following:
· Explain what pertinent information, generally, is required in documentation to support DSM-5 and ICD-10 coding. · Explain what pertinent documentation is missing from the case scenario, and what other information would be helpful to narrow your coding and billing options. · Finally, explain how to improve documentation to support coding and billing for maximum reimbursement.] |
we need to know what previous tx has the pt RECEIVED?
did she go to intensive tx, dbt,
when did the failed medication trial happen?
when was the flueoxitine prescribed?
we need moore information on pt’s adherence to medication PLAN, whats her believe about medication, did she choose to follow a medication plan or not? was she refered to a trauma rx?
met with HER FROM 9am -9:57am medication mgmt & psycho-education – spend 30mins on med mgmt & filling out paperwork and reviewed with pt,
cpt code
fluxitin is cyp2d6 inhibitor
atomoxitine is a cy2d6 substrate
vyvanse does not depend on cyp2d6
References
[Add APA-formatted citations for any sources you referenced]
Delete instructions and placeholder text when you add your citations.
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Case Study DSM-5
Use this outline to structure your case assignments.
1. Case Summary
- Provide a brief summary of what you have learned about the individual reviewed in the case. Include information about the individual in terms of demographics and general history, and the sources of that information, and the reason that the individual was referred, and by whom.
- Summarize any information you may have about evaluations that have been conducted, including the results.
2. Clinical Impression (Diagnosis)
Write the clinical impression in the DSM-5 format:
XXX.xx (Yyy.yy) Primary Diagnoses (list in order of salience).
(DSM-5 Code is first, as in XXX.xx, and ICD-10 codes next, in parentheses.)
OTHER FACTORS:
Use the V and Z codes, or simply appropriate descriptors to psychosocial and contextual factors of importance to the diagnostic case. These replace the DSM-IV-TR Axis IV & V used to address these concerns.
3. Recommendations
Explain any recommendations for interventions, treatment, and/or disposition.
4. Questions
Address the specific questions that were asked in the instructions for this assignment.
Here is a sample assignment question and an appropriate brief response:
Question: Describe what further information you would need to accurately diagnose this case.
Response: To diagnose this case accurately, I would also need to review any pertinent medical records. I would want to interview this client’s mother, with whom he lives, to corroborate the clinical interview data supplied by the client, and to learn more about his developmental history. I would also want to…
Week 3 NRNP 6635 Assignment: Assessing and Diagnosing Patients With Mood Disorders
Photo Credit: Getty Images
Accurately diagnosing depressive disorders can be challenging given their periodic and, at times, cyclic nature. Some of these disorders occur in response to stressors and, depending on the cultural history of the client, may affect their decision to seek treatment. Bipolar disorders can also be difficult to properly diagnose. While clients with a bipolar or related disorder will likely have to contend with the disorder indefinitely, many find that the use of medication and evidence-based treatments have favorable outcomes.
To Prepare:
- Review this week’s Learning Resources. Consider the insights they provide about assessing and diagnosing mood disorders.
- 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.
- By Day 1 of this week, select a specific video case study to use for this Assignment from the Video Case Selections choices in the Learning Resources. View your assigned video case and review the additional data for the case in the “Case History Reports” document, keeping the requirements of the evaluation 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.
By Day 7 of Week 3
Complete and submit your Comprehensive Psychiatric Evaluation, including your differential diagnosis and critical-thinking process to formulate a 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 patient’s 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.).
Learning Resources
Required Readings (click to expand/reduce)
American Psychiatric Association. (2013). Bipolar and related disorders. In Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author. doi:10.1176/appi.books.9780890425596.dsm03
American Psychiatric Association. (2013). Depressive disorders. In Diagnostic and statistical manual of mental disorders (5th ed.).
Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan & Sadock’s synopsis of psychiatry (11th ed.). Wolters Kluwer.
Chapter 8, Mood Disorders
Chapter 31, Child Psychiatry (Section 31.12 only)
Document: Comprehensive Psychiatric Evaluation Template
Document: Comprehensive Psychiatric Evaluation Exemplar
Required Media (click to expand/reduce)
Classroom Productions. (Producer). (2015). Bipolar disorders [Video]. Walden University.
Classroom Productions. (Producer). (2015). Depressive disorders [Video]. Walden University.
Classroom Productions. (Producer). (1992). Mood disorders [Video]. Walden University.
Classroom Productions. (Producer). (2005). Bipolar disorder in children [Video]. Walden University.
MedEasy. (2017). Mood disorders (depression, mania/bipolar, everything in between) | USMLE & COMLEX [Video]. YouTube. /orders/www.youtube.com/watch?v=59umGpQyaHs
Video Case Selections for Assignment (click to expand/reduce)
Select one of the following videos to use for your Assignment this week. Then, access the document “Case History Reports” and review the additional data about the patient in the specific video number you selected.
Symptom Media. (Producer). (2016). Training title 2 [Video]. /orders/video-alexanderstreet-com.ezp.waldenulibrary.org/watch/training-title-2
Symptom Media. (Producer). (2016). Training title 8 [Video]. /orders/video-alexanderstreet-com.ezp.waldenulibrary.org/watch/training-title-8
Symptom Media. (Producer). (2017). Training title 18 [Video]. /orders/video-alexanderstreet-com.ezp.waldenulibrary.org/watch/training-title-18
Symptom Media. (Producer). (2016). Training title 28 [Video]. /orders/video-alexanderstreet-com.ezp.waldenulibrary.org/watch/training-title-28
Symptom Media. (Producer). (2016). Training title 38 [Video]. /orders/video-alexanderstreet-com.ezp.waldenulibrary.org/watch/training-title-38
Symptom Media. (Producer). (2016). Training title 43 [Video]. /orders/video-alexanderstreet-com.ezp.waldenulibrary.org/watch/training-title-43
Symptom Media. (Producer). (2018). Training title 118 [Video]. /orders/video-alexanderstreet-com.ezp.waldenulibrary.org/watch/training-title-118
Symptom Media. (Producer). (2018). Training title 144 [Video]. /orders/video-alexanderstreet-com.ezp.waldenulibrary.org/watch/training-title-144
Symptom Media. (Producer). (2018). Training title 150 [Video]. /orders/video-alexanderstreet-com.ezp.waldenulibrary.org/watch/training-title-150
Document: Case History Reports
USE ONE VIDEO AND WRITE ON.
USE 6 RESOURCES AND REFERENCES
NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template
Week (enter week #): (Enter assignment title)
Student Name
College of Nursing-PMHNP, Walden University
NRNP 6635: Psychopathology and Diagnostic Reasoning
Faculty Name
Assignment Due Date
Subjective:
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:
Objective:
Physical exam: if applicable
Diagnostic results:
Assessment:
Mental Status Examination:
Differential Diagnoses:
Reflections:
References
NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Exemplar
INSTRUCTIONS ON HOW TO USE EXEMPLAR AND TEMPLATE—READ CAREFULLY
If you are struggling with the format or remembering what to include, follow the Comprehensive Psychiatric Evaluation Template AND the Rubric as your guide. It is also helpful to review the rubric in detail in order not to lose points unnecessarily because you missed something required. Below highlights by category are taken directly from the grading rubric for the assignment in Weeks 4–10. After reviewing the full details of the rubric, you can use it as a guide.
In the Subjective section, provide:
· Chief complaint
· History of present illness (HPI)
· Past psychiatric history
· Medication trials and current medications
· Psychotherapy or previous psychiatric diagnosis
· Pertinent substance use, family psychiatric/substance use, social, and medical history
· Allergies
· ROS
· Read rating descriptions to see the grading standards!
In the Objective section, provide:
· Physical exam documentation of systems pertinent to the chief complaint, HPI, and history
· Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses.
· Read rating descriptions to see the grading standards!
In the Assessment section, provide:
· Results of the mental status examination, presented in paragraph form.
· At least three differentials with supporting evidence. List them from top priority to least 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 .
· Read rating descriptions to see the grading standards!
Reflect on this case. Include: Discuss what you learned and what you might do differently. 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.).
(The comprehensive evaluation is typically the initial new patient evaluation. You will practice writing this type of note in this course. You will be ruling out other mental illnesses so often you will write up what symptoms are present and what symptoms are not present from illnesses to demonstrate you have indeed assessed for all illnesses which could be impacting your patient. For example, anxiety symptoms, depressive symptoms, bipolar symptoms, psychosis symptoms, substance use, etc.) EXEMPLAR BEGINS HERE
CC (chief complaint): A brief statement identifying why the patient is here. This statement is verbatim of the patient’s own words about why presenting for assessment. For a patient with dementia or other cognitive deficits, this statement can be obtained from a family member.
HPI: Begin this section with patient’s initials, age, race, gender, purpose of evaluation, current medication and referral reason. For example:
N.M. is a 34-year-old Asian male presents for psychiatric evaluation for anxiety. He is currently prescribed sertraline which he finds ineffective. His PCP referred him for evaluation and treatment.
Or
P.H., a 16-year-old Hispanic female, presents for psychiatric evaluation for concentration difficulty. She is not currently prescribed psychotropic medications. She is referred by her therapist for medication evaluation and treatment.
Then, this section continues with the symptom analysis for your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis.
Paint a picture of what is wrong with the patient. First what is bringing the patient to your evaluation. Then, include a PSYCHIATRIC REVIEW OF SYMPTOMS. The symptoms onset, duration, frequency, severity, and impact. Your description here will guide your differential diagnoses. You are seeking symptoms that may align with many DSM-5 diagnoses, narrowing to what aligns with diagnostic criteria for mental health and substance use disorders.
Past Psychiatric History: This section documents the patient’s past treatments. Use the mnemonic Go Cha MP.
General Statement: Typically, this is a statement of the patients first treatment experience. For example: The patient entered treatment at the age of 10 with counseling for depression during her parents’ divorce. OR The patient entered treatment for detox at age 26 after abusing alcohol since age 13.
Caregivers are listed if applicable.
Hospitalizations: How many hospitalizations? When and where was last hospitalization? How many detox? How many residential treatments? When and where was last detox/residential treatment? Any history of suicidal or homicidal behaviors? Any history of self-harm behaviors?
Medication trials: What are the previous psychotropic medications the patient has tried and what was their reaction? Effective, Not Effective, Adverse Reaction? Some examples: Haloperidol (dystonic reaction), risperidone (hyperprolactinemia), olanzapine (effective, insurance wouldn’t pay for it)
Psychotherapy or Previous Psychiatric Diagnosis: This section can be completed one of two ways depending on what you want to capture to support the evaluation. First, does the patient know what type? Did they find psychotherapy helpful or not? Why? Second, what are the previous diagnosis for the client noted from previous treatments and other providers. Thirdly, you could document both.
Substance Use History: This section contains any history or current use of caffeine, nicotine, illicit substance (including marijuana), and alcohol. Include the daily amount of use and last known use. Include type of use such as inhales, snorts, IV, etc. Include any histories of withdrawal complications from tremors, Delirium Tremens, or seizures.
Family Psychiatric/Substance Use History: This section contains any family history of psychiatric illness, substance use illnesses, and family suicides. You may choose to use a genogram to depict this information. Be sure to include a reader’s key to your genogram or write up in narrative form.
Social History: This section may be lengthy if completing an evaluation for psychotherapy or shorter if completing an evaluation for psychopharmacology. However, at a minimum, please include:
Where patient was born, who raised the patient
Number of brothers/sisters (what order is the patient within siblings)
Who the patient currently lives with in a home? Are they single, married, divorced, widowed? How many children?
Educational Level
Hobbies:
Work History: currently working/profession, disabled, unemployed, retired?
Legal history: past hx, any current issues?
Trauma history: Any childhood or adult history of trauma?
Violence Hx: Concern or issues about safety (personal, home, community, sexual (current & historical)
Medical History: This section contains any illnesses, surgeries, include any hx of seizures, head injuries.
Current Medications: Include dosage, frequency, length of time used, and reason for use. Also include OTC or homeopathic products.
Allergies: Include medication, food, and environmental allergies separately. Provide a description of what the allergy is (e.g., angioedema, anaphylaxis). This will help determine a true reaction vs. intolerance.
Reproductive Hx: Menstrual history (date of LMP), Pregnant (yes or no), Nursing/lactating (yes or no), contraceptive use (method used), types of intercourse: oral, anal, vaginal, other, any sexual concerns
ROS: Cover all body systems that may help you include or rule out a differential diagnosis. Please note: THIS IS DIFFERENT from a physical examination!
You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.
Example of Complete ROS:
GENERAL: No weight loss, fever, chills, weakness, or fatigue.
HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.
RESPIRATORY: No shortness of breath, cough, or sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.
GENITOURINARY: Burning on urination, urgency, hesitancy, odor, odd color
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness.
HEMATOLOGIC: No anemia, bleeding, or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.
Physical exam (If applicable and if you have opportunity to perform—document if exam is completed by PCP): From head to toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head-to-toe format i.e., General: Head: EENT: etc.
Diagnostic results: Include any labs, X-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines).
A ssessment
Mental Status Examination: For the purposes of your courses, this section must be presented in paragraph form and not use of a checklist! This section you will describe the patient’s appearance, attitude, behavior, mood and affect, speech, thought processes, thought content, perceptions (hallucinations, pseudohallucinations, illusions, etc.)., cognition, insight, judgment, and SI/HI. See an example below. You will modify to include the specifics for your patient on the above elements—DO NOT just copy the example. You may use a preceptor’s way of organizing the information if the MSE is in paragraph form.
He is an 8-year-old African American male who looks his stated age. He is cooperative with examiner. He is neatly groomed and clean, dressed appropriately. There is no evidence of any abnormal motor activity. His speech is clear, coherent, normal in volume and tone. His thought process is goal directed and logical. There is no evidence of looseness of association or flight of ideas. His mood is euthymic, and his affect appropriate to his mood. He was smiling at times in an appropriate manner. He denies any auditory or visual hallucinations. There is no evidence of any delusional thinking. He denies any current suicidal or homicidal ideation. Cognitively, he is alert and oriented. His recent and remote memory is intact. His concentration is good. His insight is good.
Differential Diagnoses: You must have at least three differentials with supporting evidence. Explain what rules each differential in or out and justify your primary diagnosis selection. You will use supporting evidence from the literature to support your rationale. Include pertinent positives and pertinent negatives for the specific patient case.
Also included in this section is the reflection. Reflect on this case and discuss whether or not you agree with your preceptor’s assessment and diagnostic impression of the patient and why or why not. What did you learn from this case? What would you do differently?
Also include in your reflection a discussion related to legal/ethical considerations (demonstrating 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.).
References (move to begin on next page)
You are required to include at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines which relate to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting.
NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template
TRANSCRIPT OF VIDEO FILE:
00:00:00______________________________________________________________________________
00:00:00BEGIN TRANSCRIPT:
00:00:00[sil.]
00:00:15OFF CAMERA Mrs. Tilman, your husband is extremely worried about you.
00:00:20MRS. TILMAN Yes, I know that.
00:00:25OFF CAMERA Does coming her bother you?
00:00:25MRS. TILMAN Yes. Yes it does. I’ve never been to a shrink before. I don’t think I need to be here now.
00:00:35OFF CAMERA I’d like to ask you a few questions if that’s ok.
00:00:40MRS. TILMAN Yeah, that should be fine.
00:00:40OFF CAMERA How have you been feeling health wise?
00:00:45MRS. TILMAN Fine. No health problems.
00:00:45OFF CAMERA Sleep?
00:00:50MRS. TILMAN I can’t sleep much. But that’s to be expected.
00:00:50OFF CAMERA How so?
00:00:50MRS. TILMAN The baby. It cries a lot.
00:00:55OFF CAMERA And that wakes you?
00:00:55MRS. TILMAN Well I’m usually already awake.
00:01:00OFF CAMERA You have trouble sleeping?
00:01:00MRS. TILMAN Just falling asleep. Especially after the baby cries.
00:01:05OFF CAMERA What’s the baby’s name?
00:01:10MRS. TILMAN Jessica.
00:01:10OFF CAMERA Beautiful name. How old is she?
00:01:15MRS. TILMAN Two months.
00:01:15OFF CAMERA How has your appetite been lately?
00:01:20MRS. TILMAN I don’t know. It’s not big, but I want to lose weight after the pregnancy.
00:01:25OFF CAMERA You aren’t comfortable with the way you look?
00:01:30MRS. TILMAN I’m terrible. Alright. I look terrible, I feel terrible. My body is bloated. I have lines on my face, bags. I look disgusting.
00:01:45OFF CAMERA What do you do to lose weight?
00:01:50MRS. TILMAN Well, I want to run, but… I don’t get out much.
00:01:55OFF CAMERA Why?
00:01:55MRS. TILMAN Cause I’m stuck at home. I have to take care of the baby, all day long. I guess I should just get used to it. This is my life now all day long, stuck at home with the kid.
00:02:10OFF CAMERA You don’t have a nanny?
00:02:10MRS. TILMAN Who could afford one? Especially with having to pay for the kid.
00:02:15OFF CAMERA Have you said any of this to your husband?
00:02:20MRS. TILMAN To Rick?
00:02:20DR. GREY Uh huh.
00:02:20MRS. TILMAN No. I couldn’t. He’d be so disappointed in me. How could I even tell him that I felt this way. That I wanted out. He comes home from work and… he plays with Jessica. This perfect family.
00:02:50OFF CAMERA How has your relationship been?
00:02:55MRS. TILMAN Not good.
00:02:55OFF CAMERA What’s happened since Jessica was born?
00:03:00MRS. TILMAN It’s not added much. I mean it is my fault. I can’t stop crying. All the time. [she cries] Sometimes I don’t even know who the baby is. And I yell a lot. Things just upset me. Everything and anything he does lately just upsets me.
00:03:35OFF CAMERA For instance?
00:03:40MRS. TILMAN Well… Well the other day he came home and changed her diaper but he threw the dirty diaper in the wrong trash can and he didn’t tie it up in the bag the way he was supposed to.
00:03:55OFF CAMERA And that upset you?
00:03:55MRS. TILMAN Yeah. And I told him, and I was yelling so he started yelling. So yeah. That’s our marriage right now.
00:04:10OFF CAMERA Have you been sexually active since Jessica was born?
00:04:10MRS. TILMAN No. Not really. I have no drive or desire. Rick keeps wanting to but I just… I push him away.
00:04:20OFF CAMERA And how is your social life?
00:04:25MRS. TILMAN Non-existent. I haven’t seen my friends in forever. They came over to see the baby but that’s about it. I might as well get used to it. I can’t go out anymore. She’s too young for a baby sitter, and even then we couldn’t afford one. I had to quit my job.
00:04:55OFF CAMERA Were you forced to quit?
00:05:00MRS. TILMAN No. They gave me maternity leave, but… but I figured this is never going to end. I might as well leave now.
00:05:10OFF CAMERA Do you do anything for yourself? Something to relax, something creative?
00:05:15MRS. TILMAN No. I tried writing. I liked writing but… I don’t know, I… nothing moves me.
00:05:30OFF CAMERA You can’t write now?
00:05:35MRS. TILMAN I have no inspiration, and it’s not fun. I know I’m going to be interrupted soon anyway. Before Jessica, I could write for hours a night. I hated anyone disturbing me. [she cries] Now I can’t have twenty minutes. And you can’t tell a baby to hold on with wanting her lunch. For an hour. When she’s hungry, she’s hungry.
00:06:05OFF CAMERA Do you regret having a child?
00:06:05MRS. TILMAN No. I… I’m just not sure. I’m not sure, okay.
00:06:20OFF CAMERA Are you happy? Does anything give you pleasure?
00:06:30MRS. TILMAN [Shakes her head] No. [she cries]. Look, please, I… I know I’m a mother now. I. [sigh] I don’t know how to put this, I feel terrible. [Cries harder]. I don’t want to be a bad mother. I love my daughter. But I don’t know… I don’t know why I say these things. It’s just really difficult… and Rick, I see Rick and he has this look. It’s this look, its like I know what you’re thinking. It’s like he’s judging me. It’s like he knows I’m not normal. I mean, what’s wrong with me? Sometimes I can’t even hold my own child, I… I, she’s crying and I can’t… I can’t touch her. And when I give her milk it disgusts me. I don’t know what to do. I don’t know what’s wrong with me. I don’t know what’s wrong with me. [She reaches for a tissue]
00:08:15OFF CAMERA Mrs. Tilman, do you have thoughts of suicide or death?
00:08:20[she shakes her head yes]
00:08:25OFF CAMERA Have you acted upon them?
00:08:30MRS. TILMAN [she shakes her head no] No. I couldn’t. I couldn’t do that to Rick or Jessica. And then I feel guilty again. It’s this… this endless cycle. I’m not happy and I want to get out and if I get out, then I would just… I would just… just ruin everyone and that makes me more unhappy.
00:09:05[sil.]
00:09:20SymptomMedia Visual Learning for Behavioral Health www.symptommedia.com
00:09:20END TRANSCRIPT
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