TO PREPARE:
· 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.
· Review 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.
Instructions
Complete and submit your Comprehensive Psychiatric Evaluation, including your differential diagnosis and critical-thinking process to formulate 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-TR diagnostic criteria for each differential diagnosis and explain what DSM-5-TR 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.).
Training Title 40 Name: Ms. Connie WeidreGender: femaleAge: 53 years oldT- 99.0 P- 102 R 24 156/86 Ht 5’4 Wt 1lbs73Background: Lives with her husband in Memphis, TN, has one daughter age 25. She has neverworked. Raised by mother, she never knew her father. Mother with hx of generalized anxiety andwas verbally abusive, abused benzodiazepines; no substance hx for patient. No previouspsychiatric treatment. Has one glass red wine with dinner. Sleeps 12-13 hrs.; appetite decreased.Has overactive bladder, untreated. Allergic to Zofran; complains of headaches, takes prnTylenol, has diarrhea 2-3 times weekly, takes OTC Imodium.Symptom Media. (Producer). (2016).
Training title 40 [Video].
https://video.alexanderstreet.com/p/K86QlW9Jl