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Assignment: Assessing and Diagnosing Patients With Mood Disorders

 

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Accurately diagnosing depressive disorders can be challenging given their periodic and, at times, cyclic nature. Some of these disorders occur in response to stressors and, depending on the cultural history of the client, may affect their decision to seek treatment. Bipolar disorders can also be difficult to properly diagnose. While clients with a bipolar or related disorder will likely have to contend with the disorder indefinitely, many find that the use of medication and evidence-based treatments have favorable outcomes.

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. 

By Day 7 of Week 3

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 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.).

 

Rubric Detail

 

A rubric lists grading criteria that instructors use to evaluate student work. Your instructor linked a rubric to this item and made it available to you. Select Grid View or List View to change the rubric’s layout.

Content

Name: NRNP_6635_Week3_Assignment_Rubric

 

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List View

  Excellent Good Fair Poor

Create documentation in the Comprehensive Psychiatric Evaluation Template about the patient you selected.

 

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 Points Range:18 (18.00%) – 20 (20.00%)

The response throughly 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. Points Range:16 (16.00%) – 17 (17.00%)

The response 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. Points Range:14 (14.00%) – 15 (15.00%)

The response 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, but is somewhat vague or contains minor innacuracies. Points Range:0 (0.00%) – 13 (13.00%)

The response provides an incomplete or inaccurate description of 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. Or, subjective documentation is missing.

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. Points Range:18 (18.00%) – 20 (20.00%)

The response thoroughly and accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are thoroughly and accurately documented. Points Range:16 (16.00%) – 17 (17.00%)

The response accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are accurately documented. Points Range:14 (14.00%) – 15 (15.00%)

Documentation of the patient’s physical exam is somewhat vague or contains minor innacuracies. Diagnostic tests and their results are documented but contain minor innacuracies. Points Range:0 (0.00%) – 13 (13.00%)

The response provides incomplete or inaccurate documentation of the patient’s physical exam. Systems may have been unnecessarily reviewed, or, objective documentation is missing.

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. Points Range:23 (23.00%) – 25 (25.00%)

The response thoroughly and accurately documents the results of the mental status exam.

 

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. Points Range:20 (20.00%) – 22 (22.00%)

The response accurately documents the results of the mental status exam.

 

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 an accurate justification for each of the disorders selected. Points Range:18 (18.00%) – 19 (19.00%)

The response documents the results of the mental status exam with some vagueness or innacuracy.

 

Response lists at least three different possible disorders for a differential diagnosis of the patient and provides a justification for each, but may contain some vaguess or innacuracy. Points Range:0 (0.00%) – 17 (17.00%)

The response provides an incomplete or inaccurate description of the results of the mental status exam and explanation of the differential diagnoses. Or, assessment documentation is missing.

Reflect on this case. 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.). Points Range:9 (9.00%) – 10 (10.00%)

Reflections are thorough, thoughtful, and demonstrate critical thinking. Points Range:8 (8.00%) – 8 (8.00%)

Reflections demonstrate critical thinking. Points Range:7 (7.00%) – 7 (7.00%)

Reflections are somewhat general or do not demonstrate critical thinking. Points Range:0 (0.00%) – 6 (6.00%)

Reflections are incomplete, inaccurate, or missing.

Provide at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support your diagnostics and differential diagnoses. Be sure they are current (no more than 5 years old). Points Range:14 (14.00%) – 15 (15.00%)

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. Points Range:12 (12.00%) – 13 (13.00%)

The response provides at least three current, evidence-based resources from the literature that appropriately support the assessment and diagnosis of the patient in the assigned case study. Points Range:11 (11.00%) – 11 (11.00%)

Three evidence-based resources are provided to support assessment and diagnosis of the patient in the assigned case study, but they may only provide vague or weak justification. Points Range:0 (0.00%) – 10 (10.00%)

Two or fewer resources are provided to support assessment and diagnosis decisions. The resources may not be current or evidence based.

Written Expression and Formatting—Paragraph development and organization:

Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused—neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria. Points Range:5 (5.00%) – 5 (5.00%)

Paragraphs and sentences follow writing standards for flow, continuity, and clarity.

 

A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria. Points Range:4 (4.00%) – 4 (4.00%)

Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time.

 

Purpose, introduction, and conclusion of the assignment are stated, yet they are brief and not descriptive. Points Range:3.5 (3.50%) – 3.5 (3.50%)

Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time.

 

Purpose, introduction, and conclusion of the assignment is vague or off topic. Points Range:0 (0.00%) – 3 (3.00%)

Paragraphs and sentences follow writing standards for flow, continuity, and clarity less than 60% of the time.

 

No purpose statement, introduction, or conclusion were provided.

Written Expression and Formatting—English writing standards:

Correct grammar, mechanics, and punctuation Points Range:5 (5.00%) – 5 (5.00%)

Uses correct grammar, spelling, and punctuation with no errors Points Range:4 (4.00%) – 4 (4.00%)

Contains a few (one or two) grammar, spelling, and punctuation errors Points Range:3 (3.00%) – 3 (3.00%)

Contains several (three or four) grammar, spelling, and punctuation errors Points Range:0 (0.00%) – 2 (2.00%)

Contains many (≥ five) grammar, spelling, and punctuation errors that interfere with the reader’s understanding

 

Training title 28

Name: Mrs. Louise Carson Gender: female Age: 49 years old T- 98.8 P- 99 R 20 150/88 Ht 5’5 Wt 135lbs Background: Currently living in Indianapolis, IN, working full-time as a logistics buyer in a medical facility. Has an MBA. Lives with her husband and three children, three boys who are all teenagers. Born and raised in Indianapolis, IN with her mother and two sisters. Father deceased in MVA when she was 2 years old. Sister has depression; mother has history of being a “functioning alcoholic”. Recently informed by her PCP she has a “fatty liver.” Allergies: latex Symptom Media. (Producer). (2016). Training title 28 [Video]. https://video-alexanderstreet-com.ezp.waldenulibrary.org/watch/training-title-28

 

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