Chief compliant (CC). His chief complaint is, "depress and anxiety due to divorce".
HISTORY: Patient is a 44 years old Caucasian male patient with history of hyperlipemia, Alcohol use disorder,
cannabis use, tobacco use, generalized anxiety disorder, Major depressive disorder that is
managed on lamotrigine, hydroxyzine, Propanolol in the past. He is on Lexopro 10mg daily and
Clonazepam 0.5mg BID. He does CBT with Mid Atlantic therapist. He endorsed tolerability and
adherence.
Symptoms/Behavior Patient reported that his divorced was finalized in 2019 to his wife of 14 years. Patient endorsed
working as engineer at Verizon and has another degree in psychology. Patient endorse improved
low energy, lack of motivation, anhedonia, poor appetite, poor sleep, irritability, anxiety, isolative,
but denies hopelessness, hopelessness, and guilty feelings. Patient endorsed improved nervous,
uncontrol worries, irritability, worrying about different things, anxious and fear of impending doom.
Patient endorsed improved racing thoughts, mood swings, irritable, impulsivity, spending spree,
grandiosity, and risky behaviors. Patient denies mania, hypomania, PTSD and psychosis. Patient
denies history of abuse or trauma. Patent reported sleeps 8 hours nightly without of nightmares.
Patient with history AUD, reported his last alcohol use to be November 2020. Patient smoked
1PPD cigarette smoker for 30 years endorsed vaping now. He last Cannabis use was yesterday
August 13, 2021. He denies other recreational drugs. He denies audio / visual hallucination. Patient
denies death wish, he vehemently suicidal and homicidal ideation, intent or plain and verbally
contracted safety. Patient reported atheist faith, his friends, and family, his dog (Amber) as his
protective factor.
7/17/1977DOB:
PAST PSYCHIATRIC HISTORY:
Addiction/Use History: Alcohol use disorder,
Tobacco use,
Psychotropic Medication History:
lamotrigine, hydroxyzine, Propanolol in the past.
He is on Lexapro 10mg daily and Clonazepam 0.5mg BID.
Outpatient Treatment:
He does CBT with Mid Atlantic therapist.
SOCIAL/DEVELOPMENTAL HISTORY:
Mr. Rice is a divorced 44 year old man. He is Not Hispanic or Latino. He is a Atheist. His
emergency contact is his Elizabeth Rice
Development History:
Details of Mr. Rice’s developmental history are not available at this time.
FAMILY HISTORY:
Father has depression, Brain tumor and TBI.
Mother had GAD.
Sister was Depression and anxiety
MEDICAL HISTORY:
hyperlipemia
EXAM: Mr. Rice appears sad looking, He exhibits speech that is normal in rate, volume, and
articulation and is coherent and spontaneous. Language skills are intact. Signs of moderate
depression are present. Signs of moderate depression are present. Affect is appropriate, full
range, and congruent with mood. There are no apparent signs of hallucinations, delusions, bizarre
behaviors, or other indicators of psychotic process. Associations are intact, thinking is logical, and
thought content appears appropriate. Suicidal ideas or intentions are denied. Homicidal ideas or
intentions are denied. Insight into problems appears normal. Judgment appears intact. There are
signs of anxiety.
Assignment 2: Comprehensive Psychiatric Evaluation and Patient Case Presentation
Comprehensive psychiatric evaluations are a way to reflect on your practicum experiences and connect the experiences to the learning you gain from your weekly Learning Resources. Comprehensive notes, such as the ones required in this practicum course, are often used in clinical settings to document patient care.
For this Assignment, you will document information about a patient that you examined during the last 7 weeks, using the Comprehensive Psychiatric Evaluation Template provided. You will then use this note to develop and record a case presentation for this patient.
To Prepare
Select a patient that you examined during the last 7 weeks. Review prior resources on the disorder this patient has.
It is recommended that you use the Kaltura Personal Capture tool to record and upload your assignment.
Conduct a Comprehensive Psychiatric Evaluation on this patient using the template provided in the Learning Resources. All psychiatric evaluations must be signed, and each page must be initialed by your Preceptor. When you submit your document, you should include the complete Comprehensive Psychiatric Evaluation as a Word document, as well as a PDF/images of each page that is initialed and signed by your Preceptor. You must submit your document using SafeAssign. Please Note: Electronic signatures are not accepted. If both files are not received by the due date, Faculty will deduct points per the Walden Late Policies.
Develop a video case presentation, based on your progress note of this patient, that includes chief complaint; history of present illness; any pertinent past psychiatric, substance use, medical, social, family history; most recent mental status exam; and current psychiatric diagnosis, including differentials that were ruled out.
Include at least five (5) scholarly resources to support your assessment and diagnostic reasoning.
Ensure that you have the appropriate lighting and equipment to record the presentation.
Assignment
Present the full case. Include chief complaint; history of present illness; any pertinent past psychiatric, substance use, medical, social, family history; most recent mental status exam; and current psychiatric diagnosis, including differentials that were ruled out.
Report normal diagnostic results as the name of the test and “normal” (rather than specific value). Abnormal results should be reported as a specific value.
Be succinct in your presentation, and do not exceed 8 minutes. Address the following:
Subjective: What details did the patient provide regarding their personal and medical history? What are their symptoms of concern? How long have they been experiencing them, and what is the severity? How are their symptoms impacting their functioning?
Objective: What observations did you make during the interview and review of systems?
Assessment: What were your differential diagnoses? Provide a minimum of three (3) possible diagnoses. List them from highest to lowest priority. What was your primary diagnosis, and why?
Reflection notes: What would you do differently in a similar patient evaluation?
