Week 3 Assignment instructions, please adhere, (4 recent references)
This week, we will explore the assessment and diagnosis of clients with mood disorders.
How would you approach your assessment? Would you ask to include family members for collateral information? What tests or assessments would you order or conduct? Are there any referrals from which your patient could benefit? How would you promote overall health and disease prevention?
Please note that the video cases may not have all the necessary information needed for your evaluation. Supplementary case histories are provided. Rather than write “not provided” in your evaluations, be sure to use the fact sheets to fill in gaps. For any information still missing, explain what information is needed and why it is important.
Select one of the videos in this week’s resources to use for your Assignment this week. Then, access the document “Case History Reports” and review the additional data about the patient in the specific video number you selected.
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.).
My differential diagnosis (YOU MAY COME UP WITH YOURS)
Seasonal Affective Mood Disorder:
Distinct Adjustment Disorder:
Unspecified Mood disorder
VIDEO TRANSCRIPT
BEGIN TRANSCRIPT:
00:00:00[sil.]
00:00:15OFF CAMERA Why did your mom feel you should come in and talk with me today?
00:00:20MRS HOUSTON She was worried. Mom says I get moody this time of year, every year. I don’t know. Maybe.
00:00:40OFF CAMERA How are you feeling, when?
00:00:45PATIENT Not great.
00:00:45OFF CAMERA What’s not great?
00:00:50PATIENT Huh. Just down. I’m not doing so well.
00:01:05OFF CAMERA How’s school?
00:01:05PATIENT Ok.
00:01:10OFF CAMERA Just ok?
00:01:15PATIENT Yeah. I left the program at school. I mean I did and… I’m not doing so well.
00:01:25OFF CAMERA Are the courses difficult?
00:01:30[sil.]
00:01:35PATIENT I understand everything. The teachers are getting to be a bit of a pain. The classes aren’t lustrous (Sighs). I’m in this special business program, where you have to come up with a mock company. I just… I just can’t seem to get it done. That, and all my other projects. I’m already late on two of them.
00:02:25OFF CAMERA Are you having difficult concentrating?
00:02:30PATIENT Yeah. I’ll read the headlines in the newspaper and like, five seconds later, I can’t remember what I read. And my classes, when I leave the room, I don’t what we were learning about.
00:02:55OFF CAMERA Are you having any irregular sleeping or eating patterns?
00:03:05PATIENT (Sighs) I’ve gained ten pounds. Umm… I’ve slept through five of my classes this month if that answers your question.
00:03:20OFF CAMERA Have you been able to make any friends?
00:03:25PATIENT [Shrugs] Yeah. Almost immediately. The people are a lot of fun.
00:03:30OFF CAMERA What do you do with them?
00:03:35PATIENT Lately, not so much of anything.
00:03:45OFF CAMERA What happened?
00:03:50PATIENT Well, it was a blast when I arrived in August. I made friends almost immediately. We went to concerts and shows, we hung out. And we had a lot of fun.
00:04:15OFF CAMERA You don’t do any of that now?
00:04:20PATIENT They kind of annoy me a little bit. I mean nothing I can’t get over. They got really dull. They suddenly started playing board games… and then, things also got busy and with the weather, I don’t want to go outside.
00:04:45OFF CAMERA Do you particularly dislike the cold weather?
00:04:50PATIENT It’s not like I have a burning passionate hatred for the cold. I’ve always fretted fall and winter. I’m a summer girl. I like the beach and convertibles. And now…
00:05:10OFF CAMERA You can’t do any of that.
00:05:10PATIENT No. In fact you can’t do anything at all.
00:05:15OFF CAMERA Can you tell me what it is you dislike about this time of the year?
00:05:25PATIENT It’s dark. And grey. And miserable. The whole city changes, it’s not the same city that I loved in August. September was good. It was beautiful. Sunny, crisp days and, the leaves changing at the end of the month and then it just started getting worse and worse. Even… the snow is grey and black. I didn’t know snow got like that, city snow. I thought snow was white and beautiful. But city snow isn’t like that. Everything is grey. It’s miserable.
[sil.]
00:06:35SymptomMedia Visual Learning for Behavioral Health www.symptommedia.com
00:06:35END TRANSCRIPT
RUBRIC
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—
Excellent 18 (18%) – 20 (20%)
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.
Good 16 (16%) – 17 (17%)
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.
Fair 14 (14%) – 15 (15%)
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.
Poor 0 (0%) – 13 (13%)
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.—
Excellent 18 (18%) – 20 (20%)
The response thoroughly and accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are thoroughly and accurately documented.
Good 16 (16%) – 17 (17%)
The response accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are accurately documented.
Fair 14 (14%) – 15 (15%)
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.
Poor 0 (0%) – 13 (13%)
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.—
Excellent 23 (23%) – 25 (25%)
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.
Good 20 (20%) – 22 (22%)
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.
Fair 18 (18%) – 19 (19%)
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.
Poor 0 (0%) – 17 (17%)
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.).—
Excellent 9 (9%) – 10 (10%)
Reflections are thorough, thoughtful, and demonstrate critical thinking.
Good 8 (8%) – 8 (8%)
Reflections demonstrate critical thinking.
Fair 7 (7%) – 7 (7%)
Reflections are somewhat general or do not demonstrate critical thinking.
Poor 0 (0%) – 6 (6%)
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).—
Excellent 14 (14%) – 15 (15%)
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.
Good 12 (12%) – 13 (13%)
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.
Fair 11 (11%) – 11 (11%)
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.
Poor 0 (0%) – 10 (10%)
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.—
Excellent 5 (5%) – 5 (5%)
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.
Good 4 (4%) – 4 (4%)
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.
Fair 3.5 (3.5%) – 3.5 (3.5%)
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.
Poor 0 (0%) – 3 (3%)
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—
Excellent 5 (5%) – 5 (5%)
Uses correct grammar, spelling, and punctuation with no errors
Good 4 (4%) – 4 (4%)
Contains a few (one or two) grammar, spelling, and punctuation errors
Fair 3 (3%) – 3 (3%)
Contains several (three or four) grammar, spelling, and punctuation errors
Poor 0 (0%) – 2 (2%)
Contains many (≥ five) grammar, spelling, and punctuation errors that interfere with the reader’s understanding
| Total Points: 100 |
Name: NRNP_6635_Week3_Assignment_Rubric
