Description
Detailed instructions included in the assignment questions. Use the video links attached to each question for each case study. Also included are the Templete and the exemplar to be used for this assignments.
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ASSIGNMENT
Use the Comprehensive Psychiatric Evaluation Template, to complete this Assignment. Also
review the Comprehensive Psychiatric Evaluation Exemplar to see an example of a completed
evaluation document.
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Use the specific video case study for each Assignment by accessing the link.
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Consider what history would be necessary to collect from this patient.
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Consider what interview questions you would need to ask this patient.
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Identify at least three possible differential diagnoses for the patient in each case
study.
Complete and submit your Comprehensive Psychiatric Evaluation, including your differential
diagnosis and critical-thinking process to formulate a primary diagnosis. Incorporate the
following into your responses in the template:
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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?
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Objective: What observations did you make during the psychiatric assessment?
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Assessment: Discuss the patient’s 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 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.
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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.).
Use this RUBRIC for this assignment
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The response thoroughly 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.
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The response thoroughly and accurately documents the patient’s physical exam for
pertinent systems. Diagnostic tests and their results are thoroughly and accurately
documented.
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The response thoroughly and accurately documents the results of the mental status exam.
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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.
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Reflections are thorough, thoughtful, and demonstrate critical thinking
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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.
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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.
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Uses correct grammar, spelling, and punctuation with no errors
QUESTION 1
ASSESSING AND DIAGNOSING PATIENTS WITH SCHIZOPHRENIA, OTHER
PSYCHOTIC DISORDERS, AND MEDICATION-INDUCED MOVEMENT
DISORDERS
Training Title 9
Name: Ms. Fatima Branning
Gender: female
Age: 28 years old
Temp.- 98.4, Pulse- 82bpm, Resp.18cpm, BP- 124/74, Ht- 5’0, Wt- 118lbs.
Background: Raised by parents, lives alone in Coronado, CA. Only child. Works as an
administrative assistance in car sales, has a bachelor’s in hospitality. Has medical history of
scoliosis, currently treated with chiropractic care. Guarded and declined to discuss past
psychiatric history. Denied family mental health issues, declined to allow you to speak to parents
for collaborative information.
Allergies: latex; menses regular, no birth control
https://drive.google.com/file/d/1OMhlcj3_vNAFr0dujNWzpBLsekM1mOV0/view
Symptom Media. (Producer). (2016). Training title 9 [Video].
RESOURCES
***In not less than FOUR (4) pages***
Reminder: Submitted papers should include a title page, introduction, summary, and
references. Spacing should be 1.5.
***NB – This is an APA Paper. Use the references below and at least THREE (3) outside
resources. FIVE (5) Total References
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Boland, R. & Verduin, M. L. & Ruiz, P. (2022). Kaplan & Sadock’s synopsis of
psychiatry (12th ed.). Wolters Kluwer.
QUESTION 2
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Chapter 5, “Schizophrenia Spectrum and Other Psychotic Disorders”
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Chapter 2 only section 2.14, “Early-Onset Schizophrenia”
ASSESSING AND DIAGNOSING PATIENTS WITH SUBSTANCE-RELATED AND
ADDICTIVE DISORDERS
Training Title 151
Name: Daniela Petrov
Gender: female
Age:47 years old
Temp- 98.8, Pulse- 84bpm, Resp.- 20cpm, B/P- 132/90, Ht-5’8, Wt-128lbs
Background: Moved to Everett, Washington from Russia with her parents when she was 16
years old. Currently lives in Boise, Idaho. She has younger 1 brother, 3 older sisters. Denied
family mental health or substance use issues. No history of inpatient detox or rehab denied selfharm
hx; Menses regular. uses condoms for birth control Has fibromyalgia. She works part time
cashier at Save A Lot Grocery Store. Dropped out of high school in 10th grade. Sleeps 5-6 hours
on average, appetite good.
https://drive.google.com/file/d/1_HGcsj9Kq61-Uw8z_i89R0ObhMU5udm4/view
Symptom Media. (Producer). (2018). Training title 151 [Video].
RESOURCES
***In not less than FOUR (4) pages***
Reminder: Submitted papers should include a title page, introduction, summary, and
references. Spacing should be 1.5.
***NB – This is an APA Paper. Use the references below and at least THREE (3) outside
resources. FIVE (5) Total References
•
Boland, R. & Verduin, M. L. & Ruiz, P. (2022). Kaplan & Sadock’s synopsis of
psychiatry (12th ed.). Wolters Kluwer.
QUESTION 3
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Chapter 4, “Substance Use and Addictive Disorders”
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Chapter 2 only section 2.17, “Adolescent Substance Abuse”
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Chapter 27 “Ethics and Professionalism”
Neurocognitive and Neurodevelopment Disorders
Training Title 50
Name: Harold Brown
Gender: male
Age: 60 years old
Vital Signs: Temp.- 98.8, Pulse- 74, Resp.- 18, BP- 134/70, Ht – 5’10, Wt- 170lbs
Background:
Has bachelor’s degree in engineering. He dates casually, never married, no children. Has one
younger brother. Sleeps 7 hours, appetite good. Denied legal issues; MOCA 28/30 difficulty with
attention and delayed recall; ASRS-5 21/24; denied hx of drug use; enjoys one scotch drink on
the weekends with a cigar. Allergies Dilaudid; history HTN blood pressure controlled with
Cozaar 100mg daily, angina prescribed ASA 81mg po daily, valsartan 80mg daily.
Hypertriglyceridemia prescribed fenofibrate 160mg daily, has BPH prescribed tamsulosin 0.4mg
po bedtime.
https://drive.google.com/file/d/1Hj32VGmVZ3i9n-ufOoU1svO6YCUw0xO7/view
RESOURCES
***In not less than FOUR (4) pages***
Reminder: Submitted papers should include a title page, introduction, summary, and
references. Spacing should be 1.5.
***NB – This is an APA Paper. Use the references below and at least THREE (3) outside
resources. FIVE (5) Total References
•
Boland, R. & Verduin, M. L. & Ruiz, P. (2022). Kaplan & Sadock’s synopsis of
psychiatry (12th ed.). Wolters Kluwer.
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Chapter 3, “Neurocognitive Disorders”
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Chapter 2- sections 2.1 “Intellectual Disability”, 2.2 “Communication
Disorders”, 2.3 Autism Spectrum Disorder, 2.4 Attention-Deficit
Disorder, 2.5 “Specific Learning Disorder”, 2.6 “Motor Disorders”
o
Chapter 26 “Level of Care”
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Chapter 29 “End-of-Life Issues and Palliative Care
Subjective:
CC (chief complaint):
HPI:
Past Psychiatric History:
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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:
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Current Medications:
Allergies:
Reproductive Hx:
ROS:
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GENERAL:
HEENT:
SKIN:
CARDIOVASCULAR:
RESPIRATORY:
GASTROINTESTINAL:
GENITOURINARY:
NEUROLOGICAL:
MUSCULOSKELETAL:
HEMATOLOGIC:
LYMPHATICS:
ENDOCRINOLOGIC:
Objective:
Physical exam: if applicable
Comprehensive Psychiatric Evaluation Template
Diagnostic results:
Assessment:
Mental Status Examination:
Differential Diagnoses:
Reflections:
References
Page 2 of 2
Comprehensive Psychiatric Evaluation Exemplar
In the Subjective section, provide:
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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
Read rating descriptions to see the grading standards!
In the Objective section, provide:
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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.
Read rating descriptions to see the grading standards!
In the Assessment section, provide:
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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.
Read rating descriptions to see the grading standards!
Reflect on this case. Include: 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.).
(The comprehensive evaluation is typically the initial new patient evaluation. You will practice
writing this type of note in this course. You will be ruling out other mental illnesses so often you
will write up what symptoms are present and what symptoms are not present from illnesses to
demonstrate you have indeed assessed for all illnesses which could be impacting your patient.
For example, anxiety symptoms, depressive symptoms, bipolar symptoms, psychosis symptoms,
substance use, etc.)
Comprehensive Psychiatric Evaluation Exemplar
EXEMPLAR BEGINS HERE
CC (chief complaint): A brief statement identifying why the patient is here. This statement is
verbatim of the patient’s own words about why presenting for assessment. For a patient with
dementia or other cognitive deficits, this statement can be obtained from a family member.
HPI: Begin this section with patient’s initials, age, race, gender, purpose of evaluation, current
medication and referral reason. For example:
N.M. is a 34-year-old Asian male presents for psychiatric evaluation for anxiety. He is currently
prescribed sertraline which he finds ineffective. His PCP referred him for evaluation and
treatment.
Or
P.H., a 16-year-old Hispanic female, presents for psychiatric evaluation for concentration
difficulty. She is not currently prescribed psychotropic medications. She is referred by her
therapist for medication evaluation and treatment.
Then, this section continues with the symptom analysis for your note. Thorough documentation
in this section is essential for patient care, coding, and billing analysis.
Paint a picture of what is wrong with the patient. First what is bringing the patient to your
evaluation. Then, include a PSYCHIATRIC REVIEW OF SYMPTOMS. The symptoms onset,
duration, frequency, severity, and impact. Your description here will guide your differential
diagnoses. You are seeking symptoms that may align with many DSM-5-TR diagnoses,
narrowing to what aligns with diagnostic criteria for mental health and substance use disorders.
Past Psychiatric History: This section documents the patient’s past treatments. Use the
mnemonic Go Cha MP.
General Statement: Typically, this is a statement of the patients first treatment experience. For
example: The patient entered treatment at the age of 10 with counseling for depression during
her parents’ divorce. OR The patient entered treatment for detox at age 26 after abusing alcohol
since age 13.
Caregivers are listed if applicable.
Hospitalizations: How many hospitalizations? When and where was last hospitalization? How
many detox? How many residential treatments? When and where was last detox/residential
treatment? Any history of suicidal or homicidal behaviors? Any history of self-harm behaviors?
Medication trials: What are the previous psychotropic medications the patient has tried and what
was their reaction? Effective, Not Effective, Adverse Reaction? Some examples: Haloperidol
Comprehensive Psychiatric Evaluation Exemplar
(dystonic reaction), risperidone (hyperprolactinemia), olanzapine (effective, insurance wouldn’t
pay for it)
Psychotherapy or Previous Psychiatric Diagnosis: This section can be completed one of two
ways depending on what you want to capture to support the evaluation. First, does the patient
know what type? Did they find psychotherapy helpful or not? Why? Second, what are the
previous diagnosis for the client noted from previous treatments and other providers. Thirdly,
you could document both.
Substance Use History: This section contains any history or current use of caffeine, nicotine,
illicit substance (including marijuana), and alcohol. Include the daily amount of use and last
known use. Include type of use such as inhales, snorts, IV, etc. Include any histories of
withdrawal complications from tremors, Delirium Tremens, or seizures.
Family Psychiatric/Substance Use History: This section contains any family history of
psychiatric illness, substance use illnesses, and family suicides. You may choose to use a
genogram to depict this information. Be sure to include a reader’s key to your genogram or write
up in narrative form.
Social History: This section may be lengthy if completing an evaluation for psychotherapy or
shorter if completing an evaluation for psychopharmacology. However, at a minimum, please
include:
Where patient was born, who raised the patient
Number of brothers/sisters (what order is the patient within siblings)
Who the patient currently lives with in a home? Are they single, married, divorced, widowed?
How many children?
Educational Level
Hobbies:
Work History: currently working/profession, disabled, unemployed, retired?
Legal history: past hx, any current issues?
Trauma history: Any childhood or adult history of trauma?
Violence Hx: Concern or issues about safety (personal, home, community, sexual (current &
historical)
Medical History: This section contains any illnesses, surgeries, include any hx of seizures, head
injuries.
Current Medications: Include dosage, frequency, length of time used, and reason for use. Also
include OTC or homeopathic products.
Allergies: Include medication, food, and environmental allergies separately. Provide a
description of what the allergy is (e.g., angioedema, anaphylaxis). This will help determine a true
reaction vs. intolerance.
Comprehensive Psychiatric Evaluation Exemplar
Reproductive Hx: Menstrual history (date of LMP), Pregnant (yes or no), Nursing/lactating (yes
or no), contraceptive use (method used), types of intercourse: oral, anal, vaginal, other, any
sexual concerns
ROS: Cover all body systems that may help you include or rule out a differential diagnosis.
Please note: THIS IS DIFFERENT from a physical examination!
You should list each system as follows: General: Head: EENT: etc. You should list these in
bullet format and document the systems in order from head to toe.
Example of Complete ROS:
GENERAL: No weight loss, fever, chills, weakness, or fatigue.
HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose,
Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or
edema.
RESPIRATORY: No shortness of breath, cough, or sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or
blood.
GENITOURINARY: Burning on urination, urgency, hesitancy, odor, odd color
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in
the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness.
HEMATOLOGIC: No anemia, bleeding, or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance. No polyuria or
polydipsia.
Physical exam (If applicable and if you have opportunity to perform—document if exam is
completed by PCP): From head to toe, include what you see, hear, and feel when doing your
physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and
History. Do not use “WNL” or “normal.” You must describe what you see. Always
document in head-to-toe format i.e., General: Head: EENT: etc.
Comprehensive Psychiatric Evaluation Exemplar
Diagnostic results: Include any labs, X-rays, or other diagnostics that are needed to develop the
differential diagnoses (support with evidenced and guidelines).
Assessment
Mental Status Examination: For the purposes of your courses, this section must be presented in
paragraph form and not use of a checklist! This section you will describe the patient’s
appearance, attitude, behavior, mood and affect, speech, thought processes, thought content,
perceptions (hallucinations, pseudohallucinations, illusions, etc.)., cognition, insight, judgment,
and SI/HI. See an example below. You will modify to include the specifics for your patient on
the above elements—DO NOT just copy the example. You may use a preceptor’s way of
organizing the information if the MSE is in paragraph form.
He is an 8-year-old African American male who looks his stated age. He is cooperative with
examiner. He is neatly groomed and clean, dressed appropriately. There is no evidence of any
abnormal motor activity. His speech is clear, coherent, normal in volume and tone. His thought
process is goal directed and logical. There is no evidence of looseness of association or flight of
ideas. His mood is euthymic, and his affect appropriate to his mood. He was smiling at times in
an appropriate manner. He denies any auditory or visual hallucinations. There is no evidence of
any delusional thinking. He denies any current suicidal or homicidal ideation. Cognitively, he is
alert and oriented. His recent and remote memory is intact. His concentration is good. His insight
is good.
Differential Diagnoses: You must have at least three differentials with supporting evidence.
Explain what rules each differential in or out and justify your primary diagnostic impression
selection. You will use supporting evidence from the literature to support your rationale. Include
pertinent positives and pertinent negatives for the specific patient case.
Also included in this section is the reflection. Reflect on this case and discuss whether or not
you agree with your preceptor’s assessment and diagnostic impression of the patient and why or
why not. What did you learn from this case? What would you do differently?
Also include in your reflection a discussion related to legal/ethical considerations
(demonstrating 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.).
References (move to begin on next page)
You are required to include at least three evidence-based, peer-reviewed journal articles or
evidenced-based guidelines which relate to this case to support your diagnostics and differentials
diagnoses. Be sure to use correct APA 7th edition formatting.
Comprehensive Psychiatric Evaluation Exemplar
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