Past Psychiatric History

For this Assignment, you will analyze a case study related to schizophrenia, another psychotic disorder, or a medication-induced movement disorder.

  • Review this week’s Learning      Resources and consider the insights they provide about assessing and      diagnosing psychotic disorders. Consider whether experiences of      psychosis-related symptoms are always indicative of a diagnosis of      schizophrenia. Think about alternative diagnoses for psychosis-related      symptoms.
  • 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, you will be assigned to a specific video case study for this      Assignment. View your assigned video case, keeping the requirements of the      documentation 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.

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      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.).

NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template

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:

Physical exam: if applicable

Diagnostic results:

Assessment

Mental Status Examination:

Differential Diagnoses:

Reflections:

References

https://ezp.waldenulibrary.org/login?qurl=https://video.alexanderstreet.com/watch/training-title-24

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