JtT

Jane,

So basically it’s a psych eval that you’ve done plenty of times before, but I will need to make a video presentation of it. I will send info I have about the patient. The information I send won’t cover everything so you can make up whatever you want. And try your best to cover everything. If you can’t cover everything do not worry. I will just make some stuff up for the video. Just do what you think is best. Your work is always quality. I’ll pay you $70 for this one

I will send you 2 patients’ info. I didn’t know which would be easier for you: someone who doesn’t report a psych history who we can make things up for, or a patient who reports having multiple psych diagnoses. I will send both and you pick whichever is easier for you!

Select a group patient for whom you conducted psychotherapy for a mood disorder during the last 4 weeks. Create a Comprehensive Psychiatric Evaluation Note on this patient using the template provided in the Learning Resources. Include at least five scholarly resources to support your assessment and diagnostic reasoning.

Include subjective and objective data; assessment from most recent mental status exam; current psychiatric diagnosis including differentials that were ruled out; current psychotherapeutic plan (include one health promotion activity and one patient education strategy you provided); and patient progress toward treatment goals.

· Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What was 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 in order of highest to lowest priority and explain why you chose them. What was your primary diagnosis and why? Describe how your primary diagnosis aligns with DSM-5 diagnostic criteria and is supported by the patient’s symptoms. 

· Plan: What was your plan for psychotherapy (including one health promotion activity and one patient education strategy)? What was your plan for treatment and management, including alternative therapies? Include nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan. 

· Reflection notes: What would you do differently with this patient if you could conduct the session again? 

Patient 1

Data:

Pt met with this writer to complete his biopsychosocial assessment. Pt is a 34-year-old heterosexual male, with no children, presenting with alcohol use disorder, LU: 3/10/21. Pt reports drinking 6 beers and a pint of vodka daily x2 weeks. Pt reports his longest period of sobriety was 2 years from 2017-2019. Pt reports relapse a week after leaving RCA’s Lighthouse facility. Denies medical history or any prescribed medications. Denies psychiatric history. Pt reports no issues regarding sex, gambling, or arson. Pt reports currently living in a home with his parents. Pt reports current employment as a garbage man and has income for necessities. Pt reports he was motivated to come to treatment because he was recently missing work and did not want to lose his job. Pt is appropriate for the residential LOC.

Assessment:

D1 – Pt denies any withdrawal symptoms. No taper ordered. Residential status D2 – Denies medical hx. No prescribed medications

D3 – Denies psych hx

D4 – Contemplative stage. Pt understands his need for a full treatment stay D5 – Risks for relapse includes long battle with alcoholism, enabling parents, drinking while working

D6 – Writer recommends residential recovery or extended inpatient

Plan: Pt will interview with PRISE therapist to discuss specialty care

Patient 2

Data: Patient is a 23-year-old, single black female presenting for opioid use disorder. Pt reports using 30 mg of Percocet nasally daily for the past 4 years. Last use 3/16. Pt reports diarrhea, sweats, and anxiety. Pt ordered 7-day Subutex taper. Pt has been to treatment once in the past (at RCA Devon) but did not take treatment seriously and left after 24 hours. Pt reports an upcoming court date on 3/17 for shoplifting. Medical hx: asthma (albuterol inhaler). Psych hx: Anxiety, Depression, PTSD. No prescribed medications. Pt reports passive SI in the last 30 days but denies plan or intent. Pt has scars on her LFA from self-harm. Pt reports self-harm as a coping skill for when she is feeling too overwhelmed. Pt reported trauma from multiple deaths including but not limited to her best friend being killed in front of her as well as her dad being murdered. Pt reported history of being molested from the age of 9-12 by her uncle. Pt reported she was living with her girlfriend who uses and is not a supportive person. Pt reported she wants to work on self- love and putting herself and her sobriety first. Pt admitted under detox status.

Assessment:

D1 – Pt ordered 7-day Subutex taper. Last COWS assessment score of 3. Anxiety, sweats, diarrhea

D2 – Med hx: Asthma. Pt uses “rescue” Albuterol inhaler

D3 – Psych hx: Anxiety, Depression, PTSD. Pt has history of self-harm. Currently no SI, HI, AVH

D4 – Contemplative stage. Pt will stay for full treatment

D5 – Risks for relapse include mental illness, history of trauma, pending legal issues

D6 – Writer recommends residential recovery. Pt would benefit from stable living environment

Plan: Pt will meet with assigned treatment team to discuss plan of care

Week(enter week #): (Enter assignment title)

Student Name

College of Nursing-PMHNP, Walden University

NRNP 6645: Psychopathology and Diagnostic Reasoning

Faculty Name

Assignment Due Date

NRNP/PRAC 6645 Comprehensive Psychiatric

Evaluation Note 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:

Case Formulation and Treatment Plan:

Reflections:

References

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