NRNP 6635: Psychopathology and Diagnostic Reasoning WEEK5

WEEK 5 PRACTICUM ASSIGNMENT

Conduct a Comprehensive Psychiatric Evaluation on this patient using the template provided in the Learning Resources. There is also a completed exemplar document in the Learning Resources so that you can see an example of the types of information a completed evaluation document should contain. All psychiatric evaluations must be signed, and each page must be initialed by your Preceptor. When you submit your document, you should include the complete Comprehensive Psychiatric Evaluation as a Word document, as well as a PDF/images of each page that is initialed and signed by your Preceptor. You must submit your document 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 Late Policies.
Develop a video case presentation, based on your progress note of this patient, that includes chief complaint; history of present illness; any pertinent past psychiatric, substance use, medical, social, family history; most recent mental status exam; and current psychiatric diagnosis, including differentials that were ruled out.
Include at least five (5) scholarly resources to support your assessment and diagnostic reasoning.

 
 
 
DONT WORRY ABOUT THE VIDEO I AM DOING THAT. PLEASEJUST USE THE TEMPLATE AND THE EXAMPLE TEMPLATE AS YOUR GUIDE. CASE STUDY IS ATTACHEDTHANKS.
 
 
 
 
USE THIS CASE STUDY
 
Purpose of today’s session: Follow-up evaluation, and medicationmanagement How is the client’s progress toward managing mental health symptoms:Stable. Explain if any: 48 y/o male with a history of schizophrenia, anddepression who presents for medication management appointment. The patientreports doing well, despite currently having a cold. He also had some bad newsfrom friends, but this has not worsened his mood. He endorses taking hismedications and denies side effects. He still has some auditory hallucinations,but no command hallucinations, and he does not interact with the voices in hishead. He denies safety concerns today.
 Is medication(s) taken asdirected, per client/parent report? Yes.
Is client reporting side effect? No . Is substance abuse reported?No.
 RATIONALE FORMEDICATION(S): Check [x] with positive symptom(s): .
 
Schizophrenic Symptom [ ] delusion [X ] hallucination- auditory [] racing thoughts [ ] Irritability [ ] depressed [X ] Symptoms under controlwith medication(s).
Depressive Symptoms [ ] Anhedonia [ ] Self Isolation [ ] Poorenergy level [ ] Guilty Feelings [ ] Easily irritated to anger [ ] Poorappetite [ ] Poor sleeping [ ] Crying spell [X ] Symptoms under control withmedication(s) . ROS Chest: Denies chest pain, and palpitations Neurology:Denies dizziness and headache.
Objective 
MENTAL STATUS EXAM
General: Reports of maintaining good hygiene, cooperative
Orientation: Fully oriented to person, place, time, and situation
Psycho-motor Activity: Normal, no retardation, agitation, handwringing, tremor, abnormal movement
Mood: “I feel OK!” Affect: Appropriate, euthymic,congruent and stable to stated mood Speech: Fluent rate, soft volume,articulates contents, and spontaneous. Thought Process: Logical and linear,coherent and goal directed.
 
Thought Content: No SI, HI, no perseverance, obsession or compulsionsthoughts Perception: Denies Visual Hallucinations, has some auditoryhallucinations, not reacting to internal or external stimuli today.
Judgment: Good-help seeking, taking medication suggested asordered, engaging in the medication management
 Insight: Good insight intomental illness
Assessment
PATIENT ASSESSMENT OF THE TREATMENT AND ON-GOING CARE: Thispatient has severe, a persistent chronic mental illness that requires regularongoing assessment, psycho-pharmacology, and coordination of care. Thesetreatments would prevent higher costs, and higher level of care.
Suicide Risk Assessment: The patient is currently at a low riskfor suicide; has no suicide ideas, intentions, or plans.
 
Diagnoses attached to this encounter:
 
Schizophrenia, unspecified
 
Major depressive disorder, recurrent, unspecified
 
Plan 
 
TREATMENT AS DISCUSSED BELOW Frequent hand washing /Use of handsanitizer Discussions on Covid-19 vaccination Use of face mask / socialdistancing 6 feet from others Advised to seek immediate medical attention at ERif shortness of breaths worsens, or difficulty in breathing develops.
MEDICATION(S). Continue with current medication regime
 
Follow up for medication management in four weeks
 
MEDICATICATIONS ATTACHED TO THIS ENCOUNTER
 
Divalproex Sodium (Depakote) 250 MG Oral Tablet Delayed Release
Take 3 tablet (250 mg) by mouth 2 times per day  for mood
 
Haloperidol 5 MG Oral Tablet
Take 1 tablet (5 mg) by mouth a. for Schizophrenia
 
Olanzapine (Olanzapine) 15 MG Oral Tablet
Take 1 tablet (15 mg) by mouth daily q HS for Schizophrenia
 
Trihexyphenidyl HCl 5 MG Oral Tablet
Take 1 tablet (5 mg) by mouth 1 time per day