Female , single

Female , single

Client is a new patient with this organization. Client is being seen and states that she witness son committing suicide in April of this year. Client states, mind racing, has difficulty going to sleep and staying asleep. Sleeps only 3-4 hrs. a day and wakes up feeling lethargic. Client has nightmares and panic attacks because there was a live video recording of son suicide. Client states “she does not know how to feel, has not process son death and she still waits for him to come home through the door. Client has excessive crying, poor appetite, focus, concentration and worries all the time. Client states loss 20 lbs. in last month. Client place on Ativan 1mg tid/prn and Lexapro 10 mg daily by medical doctor on 4/28/22.Denies any HI, SI and AVH. Client states she is currently in therapy and theraphy is working well for her.

Objective
Major depression disorder
Generalized anxiety disorder
Post-traumatic disorder

Mental Status Exam

Orientation: Person, place, and time

Appearance: Neat hygiene and appearance

Behavior/Attitude: Pleasant, cooperative, isolating, restless, anxious, withdrawn, avoidant,

Speech: Normal rate and rhythm; easily understandable,

Thought Process: preoccupations noted; No si/hi; obsessive noted, No avh.

Mood: depressed, anxious, worried

Affect: Appropriate, depressed

Memory: Intact immediate, intact remote

Concentration: Intact, attentive,

Insight: Good, fair,

Judgment: Intact, fair

Assessment
Plan
RTC in 2 weeks

Change Ativan order from PRN to routine tid and increase Lexapro to 20mg po qd. Started on Prazosin 2mg q night.

Medication education given

Continue treatment with therapist

Subjective: What details did the patient provide regarding their personal and medical history? What are their symptoms of concern? How long have they been experiencing them, and what is the severity? How are their symptoms impacting their functioning?
Objective: What observations did you make during the interview and review of systems?
Assessment: What were your differential diagnoses? Provide a minimum of three (3) possible diagnoses. List them from highest to lowest priority. What was your primary diagnosis, and why?
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.

Photo ID display and professional attire–

Excellent 5 (5%) – 5 (5%)
Photo ID is displayed. The student is dressed professionally.
Good 0 (0%) – 0 (0%)

Fair 0 (0%) – 0 (0%)

Poor 0 (0%) – 0 (0%)
Photo ID is not displayed. Student must remedy this before grade is posted. The student is not dressed professionally.
Time–

Excellent 5 (5%) – 5 (5%)
The video does not exceed the 8-minute time limit.
Good 0 (0%) – 0 (0%)

Fair 0 (0%) – 0 (0%)

Poor 0 (0%) – 0 (0%)
The video exceeds the 8-minute time limit. (Note: Information presented after the 8 minutes will not be evaluated for grade inclusion.)
Description of chief complaint and history of present illness–

Excellent 5 (5%) – 5 (5%)
The student provides an accurate, clear, and complete description of the chief complaint and history of present illness.
Good 4 (4%) – 4 (4%)
The student provides an accurate description of the chief complaint and history of present illness.
Fair 2 (2%) – 3 (3%)
The student provides a vague, inaccurate, or incomplete description of the chief complaint and history of present illness, or description is missing.
Poor 0 (0%) – 1 (1%)
The student provides a completely inaccurate, or incomplete description of the chief complaint and history of present illness, or the description is missing.
Description of past psychiatric, substance use, medical, social, and family history–

Excellent 5 (5%) – 5 (5%)
The student provides an accurate, clear, and complete description of past psychiatric, substance use, medical, social, and family history.
Good 4 (4%) – 4 (4%)
The student provides an accurate description of past psychiatric, substance use, medical, social, and family history.
Fair 2 (2%) – 3 (3%)
The student provides a vague, inaccurate, or incomplete description of psychiatric, substance use, medical, social, and family history, or description is missing.
Poor 0 (0%) – 1 (1%)
The student provides a completely inaccurate, or incomplete description of psychiatric, substance use, medical, social, and family history, or description is missing.
Discussion of most recent mental status exam and observations made during interview and review of systems–

Excellent 14 (14%) – 15 (15%)
The student provides an accurate, clear, and complete discussion of results from most recent mental status exam and observations made during interview and review of systems.
Good 12 (12%) – 13 (13%)
The student provides an accurate discussion of results from most recent mental status exam and observations made during interview and review of systems.
Fair 11 (11%) – 11 (11%)
The student provides a vague, inaccurate, or incomplete discussion of results from most recent mental status exam and observations made during interview and review of systems.
Poor 0 (0%) – 10 (10%)
All or most of the discussion is inaccurate or missing.
Discussion of diagnostics with results–

Excellent 9 (9%) – 10 (10%)
The student provides an accurate, clear, and complete discussion of diagnostics with results.
Good 8 (8%) – 8 (8%)
The student provides an accurate discussion of diagnostics with results.
Fair 7 (7%) – 7 (7%)
The student provides a vague, inaccurate, or incomplete discussion of diagnostics with results.
Poor 0 (0%) – 6 (6%)
All or most of the discussion is inaccurate or missing.
Diagnostic Impression with three (3) differential diagnoses

Reflection on this case–

Excellent 23 (23%) – 25 (25%)
The student provides an accurate, clear, and complete diagnostic impression with three (3) differentials.

Reflections are thorough, thoughtful, and demonstrate critical thinking.

Reflections contain all 3 elements from the assignment directions.
Good 20 (20%) – 22 (22%)
The student provides an accurate diagnostic impression with three (3) differentials.

Reflections demonstrate critical thinking.

Reflections contain 2 of the elements from the assignment directions.
Fair 18 (18%) – 19 (19%)
The student provides a vague, inaccurate, less than 3, or incomplete diagnostic impression with differentials.

Reflections are somewhat general or do not demonstrate critical thinking.

Reflections contain 1 of the required elements from the assignment directions.
Poor 0 (0%) – 17 (17%)
All or most of the discussion is inaccurate or missing. No diagnostic impression and less than 2 differential diagnoses.

Reflections are incomplete, inaccurate, or missing.

There are no Reflections elements from the assignment directions.
Comprehensive Psychiatric Evaluation documentation–

Excellent 23 (23%) – 25 (25%)
The response clearly, accurately, and thoroughly follows the Comprehensive Psychiatric Evaluation format to document the selected patient case.
Good 20 (20%) – 22 (22%)
The response accurately follows the Comprehensive Psychiatric Evaluation format to document the selected patient case.
Fair 18 (18%) – 19 (19%)
The response follows the Comprehensive Psychiatric Evaluation format to document the selected patient case, with some vagueness and inaccuracy.
Poor 0 (0%) – 17 (17%)
The response incompletely and inaccurately follows the Comprehensive Psychiatric Evaluation format to document the selected patient case.
Presentation style–

Excellent 5 (5%) – 5 (5%)
Presentation style is exceptionally clear, professional, and focused.
Good 4 (4%) – 4 (4%)
Presentation style is clear, professional, and focused.
Fair 3 (3%) – 3 (3%)
Presentation style is mostly clear, professional, and focused
Poor 0 (0%) – 2 (2%)
Presentation style is unclear, unprofessional, and/or unfocused.
Total Points: 100

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