Comprehensive Psychiatric Evaluation Note and Patient Case Presentation

Psychiatric notes are a way to reflect on your practicum experiences and connect the experiences to the learning you gain from your weekly Learning Resources. Comprehensive psychiatric evaluation notes, such as the ones required in this practicum course, are often used in clinical settings to document patient care.

For this Assignment, you will document information about a patient that you examined at your practicum site, using the Comprehensive Psychiatric Evaluation Note Template provided. You will then use this note to develop and record a case presentation for this patient. 

To Prepare

· Review this week’s Learning Resources and consider the insights they provide about impulse-control and conduct disorders. 

· Select a patient for whom you conducted psychotherapy for an impulse control or conduct disorder during the last 6 weeks. Create a Comprehensive Psychiatric Evaluation Note on this patient using the template provided in the Learning Resources. There is also a completed template provided as an exemplar and guide. All psychiatric evaluation notes must be signed, and each page must be initialed by your Preceptor. When you submit your note, you should include the complete comprehensive evaluation note as a Word document and pdf/images of each page that is initialed and signed by your Preceptor. You must submit your note using SafeAssign. Please Note: Electronic signatures are not accepted. If both files are not received by the due date, Faculty will deduct points per the Walden Grading Policy.

· Then, based on your evaluation of this patient, develop a video presentation of the case. Plan your presentation using the Assignment rubric and rehearse what you plan to say. Be sure to review the Kaltura Media Uploader resource in the left-hand navigation of the classroom for help creating your self-recorded Kaltura video.

· Include at least five scholarly resources to support your assessment and diagnostic reasoning.

· Ensure that you have the appropriate lighting and equipment to record the presentation.

The Assignment

Record yourself presenting the complex case study for your clinical patient. In your

presentation: 

· Dress professionally with a lab coat and present yourself in a professional manner.  

· Display your photo ID at the start of the video when you introduce yourself.

· Ensure that you do not include any information that violates the principles of HIPAA (i.e., don’t use the patient’s name or any other identifying information). 

· Present the full complex case study. Be succinct in your presentation, and do not exceed 8 minutes. Include subjective and objective data; assessment from most recent mental status exam; current psychiatric diagnosis including differentials that were ruled out; current psychotherapeutic plan (include one health promotion activity and one patient education strategy you provided); and patient progress toward treatment goals.

· Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What was 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 in order of highest to lowest priority and explain why you chose them. What was your primary diagnosis and why? Describe how your primary diagnosis aligns with DSM-5 diagnostic criteria and is supported by the patient’s symptoms. 

· Plan: What was your plan for psychotherapy (including one health promotion activity and one patient education strategy)? What was your plan for treatment and management, including alternative therapies? Include nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan. 

· Reflection notes: What would you do differently with this patient if you could conduct the session again? 

Identify leadership strengths. Discuss your strengths and how they match these leadership strengths. Explore a potential plan to enhance areas that you identify in yourself as weak.  

• One full page typed and double spaced is equivalent to 250 words (your minimum required)
• References and citations should be scholarly, peer-reviewed (no blogs, WIKI, or other school of nursing website) written in Current APA Style

Question 1: A primary care NP is developing a clinical practice guideline for management of a patient population in a midsized suburban hospital. The NP should:

a. use an existing guideline from a leading research hospital.

b. follow the guideline provided by a third-party payer to help ensure reimbursement.

c. review expert opinion and experimental, anecdotal, correlational study data.

d. write the guideline to adhere to long-standing practice protocols already in use

Question 2: A primary care NP prescribes a nitroglycerin transdermal patch, 0.4 mg/hour release, for a patient with chronic stable angina. The NP should teach the patient to:

a. change the patch four times daily.
b. use the patch as needed for angina pain.
c. use two patches daily and change them every 12 hours.
d. apply one patch daily in the morning and remove in 12 hours.

Question 3: A patient is diagnosed with asthma. The primary care nurse practitioner (NP) prescribes an inhaled corticosteroid and an inhaled bronchodilator medication and provides education about how to use inhalers. At a follow-up visit 2 weeks later, the patient’s pulmonary function tests are worse. The NP should:

a. provide a detailed written asthma action plan for the patient.
b. ask the patient to describe how the medications have been used.
c. review the symptoms of an acute asthma exacerbation with the patient.
d. teach the patient to use the albuterol more often and order an oral steroid.

Question 4: A patient who will undergo surgery in implant a biosynthetic heart valve asks the primary care NP whether any medications will be necessary postoperatively. The NP should tell the patient that it will be necessary to take:

a. daily low-dose aspirin for 1 year.
b. heparin injections as needed based on activated partial thromboplastin time levels.
c. lifelong warfarin combined with enoxaparin as needed.
d. warfarin for 3 months postoperatively plus long-term aspirin.

Question 5: A patient has a BMI of 35, a fasting plasma glucose of 120 mg/dL, elevated triglycerides, and a history of myocardial infarction. The primary care NP plans to initiate dietary and lifestyle counseling and should consider prescribing:

a. ephedra.
b. orlistat (Xenical).
c. phentermine (Adipex-P).
d. phentermine and topiramate (Onexa).

Version 1

Question 1: A primary care NP is developing a clinical practice guideline for management of a patient population in a midsized suburban hospital. The NP should:

a. use an existing guideline from a leading research hospital.

b. follow the guideline provided by a third-party payer to help ensure reimbursement.

c. review expert opinion and experimental, anecdotal, correlational study data.

d. write the guideline to adhere to long-standing practice protocols already in use

Question 2: A primary care NP prescribes a nitroglycerin transdermal patch, 0.4 mg/hour release, for a patient with chronic stable angina. The NP should teach the patient to:

a. change the patch four times daily.
b. use the patch as needed for angina pain.
c. use two patches daily and change them every 12 hours.
d. apply one patch daily in the morning and remove in 12 hours.

Question 3: A patient is diagnosed with asthma. The primary care nurse practitioner (NP) prescribes an inhaled corticosteroid and an inhaled bronchodilator medication and provides education about how to use inhalers. At a follow-up visit 2 weeks later, the patient’s pulmonary function tests are worse. The NP should:

a. provide a detailed written asthma action plan for the patient.
b. ask the patient to describe how the medications have been used.
c. review the symptoms of an acute asthma exacerbation with the patient.
d. teach the patient to use the albuterol more often and order an oral steroid.

Question 4: A patient who will undergo surgery in implant a biosynthetic heart valve asks the primary care NP whether any medications will be necessary postoperatively. The NP should tell the patient that it will be necessary to take:

a. daily low-dose aspirin for 1 year.
b. heparin injections as needed based on activated partial thromboplastin time levels.
c. lifelong warfarin combined with enoxaparin as needed.
d. warfarin for 3 months postoperatively plus long-term aspirin.

Question 5: A patient has a BMI of 35, a fasting plasma glucose of 120 mg/dL, elevated triglycerides, and a history of myocardial infarction. The primary care NP plans to initiate dietary and lifestyle counseling and should consider prescribing:

a. ephedra.
b. orlistat (Xenical).
c. phentermine (Adipex-P).
d. phentermine and topiramate (Onexa).