week 8 case study psychiatric evaluation Lisa Tremblay PLEASE FOLLOW RUBRIC!

week 8 case study psychiatric evaluation  Lisa Tremblay PLEASE FOLLOW RUBRIC!

Name: Lisa Tremblay
Gender: female
Age: 33 years old
T- 100.0 P- 108 R 20 180/110 Ht 56 Wt 146lbs
Background: Lisa is in a Naples, FL detox facility thinking about long term rehab. She is
considering treatment for her Hep C+ but needs to get clean first. She has been abusing opiates,
approximately $100 daily. She admits to cannabis 12 times weekly (I have a medical card),
and 1/2 gallon of vodka daily. She has past drug paraphernalia possession arrest. Her admission
labs. abnormal for ALT 168 AST 200 ALK 250; bilirubin 2.5, albumin 3.0; her GGT is 59; UDS
positive for opiates, THC. Positive for alcohol or other drugs. BAL .308; other labs within
normal ranges. She reports sexual abuse as child ages 6-9 perpetrator being her father who went
to prison for the abuse and drug charges. She is estranged from him. Mother lives in Maine, hx
of agoraphobia and benzodiazepine abuse. Older brother has not contact with family in last 10
years, hx of opioid use. Sleeps 5-6 hrs., appetite decreased, prefers to get high instead of eating.
Allergies: azithromycin

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 patients 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-TR diagnostic criteria for each differential diagnosis and explain what DSM-5-TR 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.).

Rubric

Excellent Good Fair Poor
Create documentation in the Comprehensive Psychiatric Evaluation Template about the patient you selected.

In the Subjective section, provide:
Chief complaint
History of present illness (HPI)
Past psychiatric history
Medication trials and current medications
Psychotherapy or previous psychiatric diagnosis
Pertinent substance use, family psychiatric/substance use, social, and medical history
Allergies
ROS
18 (18%) – 20 (20%)
The response throughly and accurately describes the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis.
16 (16%) – 17 (17%)
The response accurately describes the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis.
14 (14%) – 15 (15%)
The response describes the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis, but is somewhat vague or contains minor innacuracies.
0 (0%) – 13 (13%)
The response provides an incomplete or inaccurate description of the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis. Or, subjective documentation is missing.
In the Objective section, provide:
Physical exam documentation of systems pertinent to the chief complaint, HPI, and history
Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses.
18 (18%) – 20 (20%)
The response thoroughly and accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are thoroughly and accurately documented.
16 (16%) – 17 (17%)
The response accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are accurately documented.
14 (14%) – 15 (15%)
Documentation of the patient’s physical exam is somewhat vague or contains minor innacuracies. Diagnostic tests and their results are documented but contain minor innacuracies.
0 (0%) – 13 (13%)
The response provides incomplete or inaccurate documentation of the patient’s physical exam. Systems may have been unnecessarily reviewed, or, objective documentation is missing.
In the Assessment section, provide:
Results of the mental status examination, presented in paragraph form.
At least three differentials with supporting evidence. List them from top priority to least priority. Compare the DSM-5-TR diagnostic criteria for each differential diagnosis and explain what DSM-5-TR 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.
23 (23%) – 25 (25%)
The response thoroughly and accurately documents the results of the mental status exam.

Response lists at least three distinctly different and detailed possible disorders in order of priority for a differential diagnosis of the patient in the assigned case study, and it provides a thorough, accurate, and detailed justification for each of the disorders selected.
20 (20%) – 22 (22%)
The response accurately documents the results of the mental status exam.

Response lists at least three distinctly different and detailed possible disorders in order of priority for a differential diagnosis of the patient in the assigned case study, and it provides an accurate justification for each of the disorders selected.
18 (18%) – 19 (19%)
The response documents the results of the mental status exam with some vagueness or innacuracy.

Response lists at least three different possible disorders for a differential diagnosis of the patient and provides a justification for each, but may contain some vaguess or innacuracy.
0 (0%) – 17 (17%)
The response provides an incomplete or inaccurate description of the results of the mental status exam and explanation of the differential diagnoses. Or, assessment documentation is missing.
Reflect on this case. Discuss what you learned and what you might do differently. Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), social determinates of health, 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.).
9 (9%) – 10 (10%)
Reflections are thorough, thoughtful, and demonstrate critical thinking.
8 (8%) – 8 (8%)
Reflections demonstrate critical thinking.
7 (7%) – 7 (7%)
Reflections are somewhat general or do not demonstrate critical thinking.
0 (0%) – 6 (6%)
Reflections are incomplete, inaccurate, or missing.
Provide at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support your diagnostics and differential diagnoses. Be sure they are current (no more than 5 years old).
14 (14%) – 15 (15%)
The response provides at least three current, evidence-based resources from the literature to support the assessment and diagnosis of the patient in the assigned case study. The resources reflect the latest clinical guidelines and provide strong justification for decision making.
12 (12%) – 13 (13%)
The response provides at least three current, evidence-based resources from the literature that appropriately support the assessment and diagnosis of the patient in the assigned case study.
11 (11%) – 11 (11%)
Three evidence-based resources are provided to support assessment and diagnosis of the patient in the assigned case study, but they may only provide vague or weak justification.
0 (0%) – 10 (10%)
Two or fewer resources are provided to support assessment and diagnosis decisions. The resources may not be current or evidence based.
Written Expression and FormattingParagraph development and organization:
Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focusedneither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria.
5 (5%) – 5 (5%)
A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria.

Paragraphs and sentences follow writing standards for flow, continuity, and clarity.
4 (4%) – 4 (4%)
Purpose, introduction, and conclusion of the assignment are stated, yet they are brief and not descriptive.

Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time.
3.5 (3.5%) – 3.5 (3.5%)
Purpose, introduction, and conclusion of the assignment is vague or off topic.

Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%-79% of the time.
0 (0%) – 3 (3%)
No purpose statement, introduction, or conclusion were provided.

Paragraphs and sentences follow writing standards for flow, continuity, and clarity less than 60% of the time.
Written Expression and FormattingEnglish writing standards:
Correct grammar, mechanics, and punctuation
5 (5%) – 5 (5%)
Uses correct grammar, spelling, and punctuation with no errors
4 (4%) – 4 (4%)
Contains a few (one or two) grammar, spelling, and punctuation errors
3 (3%) – 3 (3%)
Contains several (three or four) grammar, spelling, and punctuation errors
0 (0%) – 2 (2%)
Contains many ( five) grammar, spelling, and punctuation errors that interfere with the readers understanding
Total Points: 100
Name: NRNP_6635_Week8_Assignment_Rubric

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