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Tag Archives: What observations did you make during the psychiatric assessment?

April 19, 2024
April 19, 2024

NRNP 6635 Case study

Training Title 151

Name: Daniela Petrov

Gender: female

Age:47 years old

T- 98.8 P- 84 R 20 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 self-harm 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.

NRNP 6635 Case study

NRNP 6635 Case study

Symptom Media. (Producer). (2018). Training title 151 [Video].

https://go.openathens.net/redirector/waldenu.edu?url=https://video.alexanderstreet.com/watch/training-title-151

  • Review this week’s Learning Resources and consider the insights they provide.
  • Review the Comprehensive Psychiatric Evaluation template, which you will use to complete this Assignment.
  • 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.
  • 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.

NRNP 6635 Case study

BY DAY 7 OF WEEK 8

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-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.

NRNP 6635 Case study

•          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.). APA.

March 14, 2024
March 14, 2024

Mood Disorders Case Assessment

 Name: Ms. Rosario Campbell

Gender: female

Age:25 years old

T-97.7 P-70 R-18 118/72 Ht 5’3 Wt 123lbs

Background: African American.

Mood Disorders Case Assessment

chief complaint: PTSD, Low mood and Suicidal thoughts. The client said she was diagnosed with depression at age 13 or 14 and was prescribed antidepressants, which she stopped taking in order to enlist in the military.  Currently living off-base in El Paso, Texas, active duty in the Army, MOS 92M Mortuary Affairs Specialist. Grew up in McAllen TX with both parents and one brother. Completed education through high school. Currently partnered. No children. Mother history of depression; brother hx of cannabis use. No medical history. No legal hx; allergy: cipro previous medication trials: sertraline, fluoxetine both with good effects when taking. Symptom Media. (Producer). (2017). Training title 18 [Video].

Mood Disorders Case Assessment

TO PREPARE

  • Review this week’s Learning Resources. Consider the insights they provide about assessing and diagnosing mood 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.
  • 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.

Mood Disorders Case Assessment

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:

  • 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-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.

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 APA referencing style.

December 19, 2023
December 19, 2023

Anxiety Disorder Case Study

Casie Weider Gender: female Age: 53 years old T- 99.0 P- 102 R 24 156/86 Hit 5’4 Wt. 1lbs73 Background: Lith her husband in Memphis, TN, has one daughter aged 25. She has never worked. Raised by mother, she never knew her father. Mother with hex of generalized anxiety and was verbally abusive, abused benzodiazepines, no substance hex for patient. No previous psychiatric treatment. Has one glass red wine with dinner. Sleeps 12-13 hrs.; appetite decreased. Has overactive bladder, untreated. Allergic to Zofran; complains of headaches, takes prn Tylenol, has diarrhea 2-3 times weekly, takes OTC Imodium. Symptom Media. (Producer). (2016). Training title 40 [Video]

Anxiety Disorder Case Study

Anxiety Disorder Case Study

Transcript of Video:

 

00:00:00TRANSCRIPT OF VIDEO FILE:

00:00:00______________________________________________________________________________

00:00:00BEGIN TRANSCRIPT:

00:00:00[sill.]

00:00:15[She nervously plays with her scarf as she breathes anxiously]

00:00:25OFF CAMERA Hello Mrs. Wieder. Are you ok? Do you want some water or something?

00:00:30MRS. WEIDRE I’m ok. I’m fine.

00:00:35OFF CAMERA, I understand you wanted to see me today.

00:00:40[She breathes anxiously]

00:00:40MRS. WEIDRE I just really needed to sit and talk.

00:00:40OFF CAMERA Well, tell me what’s wrong, what are you feeling?

00:00:50MRS. WEIDRE I’m just so… so unsure. I’m tired of being stuck in my house. I don’t like it.

00:01:00OFF CAMERA Stuck in your house? Do you have difficultly left your house?

00:01:05MRS. WEIDRE Yes. All the time.

00:01:05OFF CAMERA When do you go out?

00:01:10MRS. WEIDRE …maybe, once or twice.

00:01:15OFF CAMERA A Day?

00:01:15[She clutches her hands to her chest]

00:01:15MRS. WEIDRE A week. Tuesdays and Saturdays.

00:01:20OFF CAMERA Why Tuesday and Saturday?

00:01:30MRS. WEIDRE Because when my husband gets home, he can go with me.

00:01:35OFF CAMERA What do you do when you go out?

00:01:40MRS. WEIDRE I take walks.

00:01:40OFF CAMERA Where do you walk?

00:01:40MRS. WEIDRE I only go to the end of the block, and then I cross the street, and turn around, and I go back around the cul-de-sac. I’ll do those three times. [Losing breathe] No more, then I have to go back inside… I also go in my backyard. That’s usually okay.

00:02:15OFF CAMERA On the walks, why do you have to go back after three times? What happens?

00:02:20MRS. WEIDRE [She nervously looks around] I just can’t go any further.

00:02:25OFF CAMERA Is this a physical problem, knees or something?

00:02:30[She plays with her scarf]

00:02:30MRS. WEIDRE No. No. Well… maybe. I just can’t breathe if I’m out any longer.

00:02:40OFF CAMERA Oh, breathing?

00:02:40MRS. WEIDRE Yeah.

00:02:40OFF CAMERA What do you feel?

00:02:45MRS. WEIDRE [Her voice quivering] I’m just so frightened. Really, really scared. You don’t realize what it took for me to get here today. I really had to. I willed it. I closed my eyes, and my husband turned the radio up all the way as he drove. And then he led me into the building.

00:03:20OFF CAMERA Is there something that triggers this, anything in particular?

00:03:30MRS. WEIDRE I don’t like people. Maybe that’s it. I mean I can tolerate them. Ethan, the little boy next door, I’ll bake things for him and say hello. Sometimes, sometimes I watch him when his parents are gone. I mean I can be around people. Maybe that’s not that’s not what I meant.

00:04:00OFF CAMERA Ok, can you walk me through what happens when you do leave the house?

00:04:05MRS. WEIDRE I get shortness of breath, everything, the world just seems to close in on me, and everything gets feels really tight, the air in my body, my chest. I get dizzy. I don’t know what’s wrong… I could be sick. What is this?

00:04:30OFF CAMERA There can be many different causes for this. What is it that frightens you?

00:04:40MRS. WEIDRE [She’s short of breath] Death. I’m afraid to die.

00:04:45OFF CAMERA You’re afraid you might die?

00:04:50MRS. WEIDRE Yes. Among other things but that’s what pops into my head.

00:04:55OFF CAMERA Is their other stuff?

00:05:00[sill.]

00:05:05MRS. WEIDRE Cars go to fast. And there’s murders and rapes that I see on the news. And flashfloods. I just think it’s close, it’s safer to stay close to home.

00:05:15OFF CAMERA How long have you had this fear?

00:05:20MRS. WEIDRE I don’t really know.

00:05:20OFF CAMERA Do you know when it all started?

00:05:25MRS. WEIDRE I’m not sure.

00:05:30OFF CAMERA Do you know what started it?

00:05:30MRS. WEIDRE No.

00:05:35OFF CAMERA When was the last time you really ventured out for any length of time?

00:05:40MRS. WEIDRE Fifteen years.

00:05:45[She nervously shifts in her chair]

00:05:45OFF CAMERA That long. Is this the farthest you’ve been in fifteen years? What happened fifteen years ago?

00:06:00MRS. WEIDRE I don’t really know.

00:06:05OFF CAMERA There is nothing that happened to you personally that could have made you afraid of dying?

00:06:10MRS. WEIDRE I always was. My mother died the year before that. But it happened little by little. First it was planes. And then I couldn’t drive on the freeway, then I couldn’t drive at all, then errands, then it was going out… and soon… here I am.

00:06:40OFF CAMERA It must have taken you extraordinary courage to come here today. What finally brought you to see me?

00:06:50MRS. WEIDRE My grandson was born. But I couldn’t go and see him. I still haven’t seen him. My daughter gave birth last week and she’s not going to bring him to see me for several months and I don’t want to wait that long.

00:07:10OFF CAMERA You miss out.

00:07:15MRS. WEIDRE Yes! Of course, I do! My grandson is a thousand miles away and I can’t leave the God damned house.

00:07:25[sill.]

00:07:25END TRANSCRIPT

Anxiety Disorder Case Study

Assignment:

Incorporate the following into your responses in the template: Comprehensive Psychiatric Evaluation

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.
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-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.).
References:

Anxiety Disorder Case Study

American Psychiatric Association. (2022). Anxiety disorders. In Diagnostic and statistical manual of mental disorders Links to an external site. (5th ed., text rev.). https://go.openathens.net/redirector/waldenu.edu?URL= https://dsm.psychiatryonline.org/doi/full/10.1176/appi.books.9780890425787.x05_Anxiety_Disorders

Med Easy. (2017). Anxiety, OCD, PTSD and related psychiatric disorders | USMLE & HomeLinks to an external site. [Video]. YouTube. https://www.youtube.com/watch?v=-BwzQF9DTlY. Use APA referencing style.