Order ID | 53563633773 |
Type | Essay |
Writer Level | Masters |
Style | APA |
Sources/References | 4 |
Perfect Number of Pages to Order | 5-10 Pages |
Assessing and Diagnosing Patients with Stress Disorders
“Fear,” according to the DSM-5, “is the emotional response to real or perceived
imminent threat, whereas anxiety is anticipation of future threat” (APA, 2013). All
anxiety disorders contain some degree of fear or anxiety symptoms (often in
combination with avoidant behaviors), although their causes and severity differ.
Trauma-related disorders may also, but not necessarily, contain fear and anxiety
symptoms, but their primary distinguishing criterion is exposure to a traumatic event.
Trauma can occur at any point in life. It might not surprise you to discover that
traumatic events are likely to have a greater effect on children than on adults.
Early-life traumatic experiences, such as childhood sexual abuse, may influence the
physiology of the developing brain. Later in life, there is a chronic hyperarousal of the
stress response, making the individual vulnerable to further stress and stress-related
disease.
For this Assignment, you practice assessing and diagnosing patients with anxiety
disorders, PTSD, and OCD. Review the DSM-5 criteria for the disorders within these
classifications before you get started, as you will be asked to justify your differential
diagnosis with DSM-5 criteria.
To Prepare:
· Review this week’s Learning Resources and consider the insights they provide
about assessing and diagnosing anxiety, obsessive-compulsive, and trauma- and
stressor-related disorders.
· Download the Comprehensive Psychiatric Evaluation Template, which you will use
to complete this Assignment. Also review the Comprehensive Psychiatric
Evaluation Exemplar to see an example of a completed evaluation document.
· By Day 1 of this week, select a specific video case study to use for this Assignment
from the Video Case Selections choices in the Learning Resources. View your
assigned video case and review the additional data for the case in the “Case History
Reports” document, keeping the requirements of the evaluation template in mind.
Assigned video
· https://video-alexanderstreet-com.ezp.waldenulibrary.org/watch/training-title-37
· Consider what history would be necessary to collect from this patient.
· Consider what interview questions you would need to ask this patient.
· Identify at least three possible differential diagnoses for the patient.
Complete and submit your Comprehensive Psychiatric Evaluation, including your
differential diagnosis and critical-thinking process to formulate primary diagnosis.
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 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 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.
· 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.).
Required Media
https://video-alexanderstreet-com.ezp.waldenulibrary.org/watch/obsessive-
compulsive-disorders
https://video-alexanderstreet-com.ezp.waldenulibrary.org/watch/obsessive-
compulsive-disorders
https://video-alexanderstreet-com.ezp.waldenulibrary.org/watch/the-neurobiology-of-
anxiety
https://video-alexanderstreet-com.ezp.waldenulibrary.org/watch/anxiety-disorders
Instructions On How to Use Exemplar and Template—Read Carefully
If you are struggling with the format or remembering what to include, follow
the Comprehensive Psychiatric Evaluation Template AND the Rubric as your guide.
It is also helpful to review the rubric in detail in order not to lose points unnecessarily
because you missed something required.
Below highlights by category are taken directly from the grading rubric for the
assignment in Weeks 4–10. After reviewing the full details of the rubric, you can use
it as a guide.
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
· Read rating descriptions to see the grading standards!
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.
· Read rating descriptions to see the grading standards!
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 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.
· 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!),
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.) 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 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 (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.
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.
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
diagnosis 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!),
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
|
||||||||||||||||||||||||||||||||
GET THIS PROJECT NOW BY CLICKING ON THIS LINK TO PLACE THE ORDERCLICK ON THE LINK HERE: https://www.perfectacademic.com/orders/ordernowAlso, you can place the order at www.collegepaper.us/orders/ordernow / www.phdwriters.us/orders/ordernow |
||||||||||||||||||||||||||||||||
|