NRNP 6635 Walden University Anxiety and Depression Comprehensive Psychiatric Evaluation Template

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” (ATTACHED BELOW) 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.

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.).
• ATTACHED IS THE VIDEO CASE STUDY AND CASE HISTORY REPORT IS LISTED BELOW
• Name: Mrs. Leslie Tilman
  Gender: female
  Age: 32 years old
  T- 97.6 P- 97 R 22 149/98 Ht 5’3 Wt 245lbs
  Background: Recently had her first child two months ago. Currently married; stay at home
  mother after working in retail for 5 years. Grew up with both parents, one sister in Omaha, NE.
  Completed education through bachelor’s level, studying physics. Previous employment included
  research science as well as high school substitute teaching for 5 years prior to birth. No
  previous suicidal gestures; has uncle who committed suicide via GSW. She denied
  drugs/alcohol; uncle was opioid abuser. Hx of HTN-prescribed labetalol 100mg twice daily,
  admits to missing doses due to forgetting. No legal hx. Allergies: codeine
  Symptom Media. (Producer). (2016). Training title 8 [Video].
• Please note that the video cases may not have all the necessary information needed for your evaluation. Supplementary case histories are provided. Rather than write “not provided” in your evaluations, be sure to use the fact sheets to fill in gaps. For any information still missing, explain what information is needed and why it is important.Select one of the videos under this week’s resources 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.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.).