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Question: COMPREHENSIVE PSYCHIATRIC EVALUATION NOTE AND PATIENT CASE PRESENTATION, PART 1

05 Oct 2024,9:13 PM 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. WEEKLY RESOURCES Be sure to review the Learning Resources before completing this activity. Click the weekly resources link to access the resources. 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 disorderduring 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 by your Preceptor. When you submit your note, you should include the complete comprehensive evaluation note as a Word document and pdf/images of the completed assignment signed by your Preceptor. You must submit your note using Turnitin.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 for your clinical patient. Do not sit and read your written evaluation! The video portion of the assignment is a simulation to demonstrate your ability to succinctly and effectively present a complex case to a colleague for a case consultation. The written portion of this assignment is a simulation for you to demonstrate to the faculty your ability to document the complex case as you would in an electronic medical record. The written portion of the assignment will be used as a guide for faculty to review your video to determine if you are omitting pertinent information or including non-essential information during your case staffing consultation video. In your presentation: Dress professionally 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-TR diagnostic criteria and is supported by the patient’s symptoms. Plan: Describe your treatment modality and your plan for psychotherapy. Explain the principles of psychotherapy that underline your chosen treatment plan to support your rationale for the chosen psychotherapy framework. What were your follow-up plan and parameters? What referrals would you make or recommend as a result of this psychotherapy session? Reflection notes: What would you do differently in a similar patient evaluation? Reflect on one social determinant of health according to the HealthyPeople 2030 (you will need to research) as applied to this case in the realm of psychiatry and mental health. As a future advanced provider, what are one health promotion activity and one patient education consideration for this patient for improving health disparities and inequities in the realm of psychiatry and mental health? Demonstrate your critical thinking Below is the details of the patient seen in the clinic: D.S is a 15-year-old African American male who was accompanied to the clinic by his parents on September 18, 2024. The patient has the habit of skin picking. The parents report that the patient bites the cuticles around her fingers all the time, and also picks the skin on her face. Whenever there is a little pimple on her face, he will pick on it until it turns into a wound. When the wound heals, and there are other pimples on another spot, he will also pick on it. The patient is diagnosed with obsessive-compulsive disorder. According to the parents, the patient is currently on daily Furosetine (Prozac) by mouth. Because medication alone is not effective to resolve this behavior, the PMHNP referred the patient to psychotherapy. This is the first week of the therapy. Patient verbalized his readiness for the sessions. Treatment plan: Continue with Psychotherapy in combination with the psychotropic medication. Counsel the patient and parents on how to identify obsessive-compulsive disorder symptoms and how to manage them. Educate the patient and parents on coping skills for skin picking (OCD).

Expert answer

Subjective Data Chief Complaint: "I can’t stop picking my skin, especially when I have a pimple." Duration and Severity of Symptoms: D.S. has been engaging in skin-picking behaviors for approximately 2 years. His parents report that the behavior worsens during stressful periods, particularly before school exam
Subjective Data Chief Complaint: D.S. is a 15-year-old African American male presenting with a primary concern of skin-picking behavior. He reports, "I can’t stop picking my skin, especially when I have a pimple." Duration and Severity of Symptoms: D.S. has been engaging in skin-picking behaviors for approximately 2 years. His parents report that the behavior worsens during stressful periods, particularly before school exams. Impact on Functioning: The skin-picking habit has resulted in visible wounds on his face and hands, causing embarrassment and social anxiety. D.S. avoids social situations, fearing that peers will notice his skin condition. Objective Data Observations: During the assessment, D.S. was alert and oriented to person, place, and time. He appeared anxious, frequently rubbing his hands and fidgeting. Physical examination revealed multiple healing wounds on his face and fingers consistent with compulsive skin-picking. Assessment Mental Status Examination: Appearance: D.S. appeared his stated age, well-groomed, but with noticeable scars and wounds. Mood and Affect: Mood described as "okay," but affect was anxious and slightly flattened. Thought Process: Logical and goal-directed; however, D.S. expressed persistent worries about his skin and how others perceive him. Differential Diagnoses: Primary Diagnosis: Obsessive-Compulsive Disorder (OCD). This aligns with DSM-5-TR criteria, specifically regarding the presence of obsessions (intrusive thoughts about skin appearance) and compulsions (skin picking). Secondary Diagnosis: Body-Focused Repetitive Behavior Disorder, given the specific nature of skin-picking, though it is likely a manifestation of his OCD. Tertiary Diagnosis: Generalized Anxiety Disorder was considered but ruled out as D.S.'s primary symptoms relate more to OCD than generalized anxiety. Plan Treatment Modality: Initiate Cognitive Behavioral Therapy (CBT) focused on exposure and response prevention to help D.S. manage his skin-picking urges. Follow-up: Schedule weekly psychotherapy sessions for the next month to monitor progress and adjust the treatment plan as needed. Patient Education: Educate D.S. and his parents about OCD symptoms and effective coping strategies, including recognizing triggers and implementing replacement behaviors (e.g., using stress balls). Health Promotion Activity: Encourage participation in a support group for teens with similar issues, fostering peer connections and shared experiences. Reflection Notes Improvements for Future Evaluations: In future sessions, I would include a more structured approach to involving D.S.’s parents, facilitating family discussions about OCD to enhance support. Social Determinant of Health: Health Literacy: Addressing health literacy is crucial. Ensuring D.S. and his parents fully understand OCD and its treatment options will empower them to manage his condition effectively. Health Promotion and Patient Education Considerations: I would promote the importance of routine skin care to minimize skin damage and suggest mindfulness practices to help D.S. cope with anxiety related to skin-picking.
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