Posted: October 13th, 2022

Comprehensive Psychiatric Evaluation Note and Patient Case Presentation

Assignment 2: Comprehensive Psychiatric Evaluation Note and Patient Case Presentation
Photo Credit: PexelsPsychiatric 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.
To PrepareReview 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 disorder during 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, and each page must be initialed by your Preceptor. When you submit your note, you should include the complete comprehensive evaluation note as a Word document and pdf/images of each page that is initialed and signed by your Preceptor. You must submit your note using SafeAssign. Choose a patient who has received psychotherapy for an impulse control or conduct disorder in the last 6 weeks. Using the template provided in the Learning Resources, create a Comprehensive Psychiatric Evaluation Note for this patient. A completed template is also provided as an example and guide. Your Preceptor must sign all psychiatric evaluation notes and initial each page. When submitting your note, include the entire comprehensive evaluation note as a Word document as well as pdf/images of each page that has been initialed and signed by your Preceptor. You must use SafeAssign to submit your note.
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.
Patient case:
Patient DD is a 19-year-old female foreign student from Ghana DX with Major depressive disorder (MDD), and Attention deficit hyperactivity disorder (ADHD). Patient reports her depression is due to a rape incident that occurred three years ago. During the intake session, DD reports that her reason for coming to the USA is to get educated. She was tearful, and anxious seen rapidly tapping feet on the floor. The patient lives on her campus during the semester and stays with her married aunt’s family in Baltimore. The patient’s aunt and husband were present during the intake process. DD’s aunt expressed concern about her niece’s mental health and wellbeing after the incident since the Ghanaian justice system failed to convict the rapist. The patient’s aunt also reports that her niece’s refusal to visit her parents during the holiday has created a rift between her and DD’s mother, which worsens her depression. Patient also stated she was managing her ADHD well until the rape incident which has triggered regression . The patient reports that she experiences nightmares when sleeping at night and has lost interest in all the fun activities that she used to do. The therapist believes that the telehealth-based patient intake session is missing vital information due to the patient’s unwillingness to discuss some of the challenges that she is facing in her life currently. The treatment plan is to use CBT to help DD recognize her feeling and develop the right coping strategy for difficult situations. Pt she denied suicidal or homicidal ideations, or visual or auditor hallucinations. She denied smoking used, alcohol use, or use of recreational drugs. Pt denied past medical history, and stated she has no allergies to drugs, environmental, latex or food, and she did receive the COVID-19 vaccine. Patient denied reproductive history, or any family history of mental illness. Medication patient is currently taking is Sertraline (Zoloft) 25mg for depression.

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