[ANSWERED 2023] Select a patient for whom you conducted psychotherapy during the last 6 weeks. Create a Comprehensive Psychiatric Evaluation Note on this patient using the template provided in the Learning Resources

Select a patient for whom you conducted psychotherapy during the last 6 weeks. Create a

Assignment 2: Comprehensive Psychiatric Evaluation Note and Patient Case Presentation

Psychiatric notes are a way to reflect on your practicum experiences and connect the experiences to the learning you gain from your weekly Learning Resources. Comprehensive psychiatric evaluation 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 at your practicum site, using the Comprehensive Psychiatric Evaluation Note Template provided. You will then use this note to develop and record a case presentation for this patient.

To Prepare

• Review this week’s Learning Resources and consider the insights they provide about impulse-control and conduct disorders.
• Select a patient for whom you conducted psychotherapy during the last 6 weeks. Create a Comprehensive Psychiatric Evaluation Note on this patient using the template provided in the Learning Resources. There is also a completed template provided as an exemplar and guide. All psychiatric evaluation notes must be signed, and each page must be initialed by your Preceptor. When you submit your note, you should include the complete comprehensive evaluation note as a Word document and pdf/images of each page that is initialed and signed by your Preceptor. You must submit your note 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 Grading Policy.
• Then, based on your evaluation of this patient, develop a video presentation of the case. Plan your presentation using the Assignment rubric and rehearse what you plan to say. Be sure to review the Kaltura Media Uploader resource in the left-hand navigation of the classroom for help creating your self-recorded Kaltura video.
• Include at least five scholarly resources to support your assessment and diagnostic reasoning.
• Ensure that you have the appropriate lighting and equipment to record the presentation.

The Assignment

Record yourself presenting the complex case study for your clinical patient. In your presentation:

• Dress professionally and present yourself in a professional manner.
• Display your photo ID at the start of the video when you introduce yourself.
• Ensure that you do not include any information that violates the principles of HIPAA (i.e., don’t use the patient’s name or any other identifying information).
• Present the full complex case study. Be succinct in your presentation, and do not exceed 8 minutes. Include subjective and objective data; assessment from most recent mental status exam; current psychiatric diagnosis including differentials that were ruled out; current psychotherapeutic plan (include one health promotion activity and one patient education strategy you provided); and patient progress toward treatment goals.
  • Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What was 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 in order of highest to lowest priority and explain why you chose them. What was your primary diagnosis and why? Describe how your primary diagnosis aligns with DSM-5 diagnostic criteria and is supported by the patient’s symptoms.
  • Plan: What was your plan for psychotherapy (including one health promotion activity and one patient education strategy)? What was your plan for treatment and management, including alternative therapies? Include nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.
  • Reflection notes: What would you do differently with this patient if you could conduct the session again?

Expert Answer and Explanation

Conduct Disorder SOAP

Subjective:

CC (chief complaint): The client’s mother complains that her child has been engaging in fights and has been so impulsive on many occasions.

HPI: DK is a 14-years-old female of White origin whose mother requested that she be connected to treatment services. The patient’s mother complains that the patient often initiates physical fights with her peers at school. She also intimidates and bullies other students. She has been physically cruel to her peers and mother on several occasions. The patient’s mother also complains that the patient has a history of violent outbursts, anger problems, and impulsivity.

When she is angry, she often punches walls and attacks others. The client also reports a feeling of stress and anxiety when she is in public and around many people. Her behaviors have deteriorated her relationship with her peers as they fear being around her. Her grades have also decreased. She has been suspended more than six times in the last three semesters for fighting her peers.

Substance Current Use: She denies substance abuse or alcohol intake at the moment.

Medical History: She denies any medical problems.

• Current Medications: No medications
• Allergies:No allergies.
• Reproductive Hx:She does not have any reproductive abnormality and is sexually inactive.

ROS:

• GENERAL: No weakness, weight loss, fatigue, or chills.
• No weight loss, fever, chills, weakness, or fatigue.
• HEENT: Eyes: No double vision, yellow sclerae, blurred vision, or visual loss. Ears, Nose, Throat: No sneezing, hearing, sore throat, or congestion.
• SKIN: No rash.
• CARDIOVASCULAR: No chest pain, edema, chest pressure, palpitations, or chest discomfort.
• RESPIRATORY: No shortness of breath, history of coughing, or sputum.
• GASTROINTESTINAL: No stomach pain, diarrhea, nausea, or anorexia.
• GENITOURINARY: No odor, urgency, odd color, hesitancy, or burning on urination.
• NEUROLOGICAL: No numbness, or tingling in the extremities, syncope, headaches, change in bladder control, or paralysis.
• MUSCULOSKELETAL: No joint or muscle pain.
• HEMATOLOGIC: No bleeding, bruising, anemia.
• LYMPHATICS: No history of splenectomy.
• ENDOCRINOLOGIC: No reports of endocrinologic abnormalities.

Objective:

Vital Signs: BP 108/79, RR 16, P 67, Temp 36.8, Ht. 63 inches, Wt. 105 lbs.

Physical Exam

• HEENT: Eyes: No glasses. The pupil size is 3.5 mm. The reactivity, symmetry, and shape of the pupil are normal. The reflection of light is symmetrical. Normal extraocular movements. Ears: Sound is heard midline showing normal hearing. No inflammation or swelling of the ear pinna and mastoid on palpation. No tragal tenderness on palpation. No ear discharge, foreign body, or wax. Nose: Normal nose structures on inspection. No deformities and the nose are symmetrical. Throat: No inflammation or swelling of the throat. No sore throat.
• Skin: No lesions or rash.
• Cardiovascular: Normal carotid arterial pulse. No murmurs on palpation. The heart sounds normal on palpation. Normal heart rhythm and heartbeat. No fluid in the feet or ankles. No edema. S1 and S2 are normal.
• Respiratory: No respiratory distress when breathing. No fluids in the lungs. No inflammation of the chest walls.

Diagnostic results:

• Child Behavior Checklist: This tool is widely used to check whether children have the impulsive disorder, conduct disorder, ADHD, and many other mental health problems affecting their behavior (Ward et al., 2020). The authors argue that the tool is widely used in screening behavior problems in youth and children. The tool shows that the patient has conduct disorder.
• The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5): The tool has criteria that should be followed when diagnosing people with mental health problems (American Psychiatric Association (APA), 2013). Based on the tool’s criteria, the patient has conduct disorder.

Assessment:

Mental Status Examination: The is a 14-year-old girl who appears her stated age. Her level of consciousness is normal. Her grooming is impressive. She wears clothes that match the weather of the day. Her posture is erect and she avoids eye contact. Her speech is normal and she reports a normal mood. Affect is aligned with mood.

She denies delusional thinking, hallucinations, illusions, suicidal, or homicidal thoughts. Her attitude and insight are normal. She is attentive and oriented to place, time, and people. Her memory is also intact.

Diagnostic Impression: 

• Conduct Disorder DSM-5 312.81 (F91.1), 312.82 
• Social Anxiety Disorder (Social Phobia) DSM-5 300.23 (F40.10)
• Intermittent Explosive Disorder (IED) DSM-5 312.34 (F63.81)

The primary diagnosis for this case is conduct disorder. Fanti et al. (2018) argue that conduct disorder is linked to impulsivity, stealing, lying, assaulting, and fighting. DMS-5 also reports that conduct disorder should be diagnosed when a patient has a persistent and repetitive pattern and behavior that violates the basic rights of other people as manifested by three or more of the following symptoms over 12 months.

They include bullying, destroying properly, initiating fights, being cruel to animals or people, and stealing just to mention a few (APA, 2013). The patient experiences three symptoms including initiating fights, bullying and being cruel to people making the disease a primary diagnosis. The patient has been suspended more than seven times for initiating fights and attacking others. Her mother notes that the problem has been going on for three semesters.

The second diagnosis is social anxiety disorder also known as social phobia. According to Koyuncu et al. (2019), social anxiety is an anxiety disorder that makes one feel so anxious when in front of people either their colleagues or strangers. These people cannot control anxiety when in a social gathering. The DSM-5 report that social anxiety is diagnosed when one has a persistent intense fear of being in front of people because they believe that they might be humiliated, negatively judged or embarrassed (APA, 2013).

The disorder can be included because the patient experiences anxiety in front of people. However, it is not a primary diagnosis because the fear is not intense and persistent. The last diagnosis is IED. IED has been included in the diagnosis because the patient experiences anger outbursts (Fanning et al., 2019). However, the disease is a secondary disorder because the patient does not meet DSM-5 characteristics.

Reflections:

What I learned from the case is that impulsive and conduct disorders are hard to distinguish because they all cause anger problems and behavior change. However, DSM-5 has provided criteria that can be used to differentiate the problems. If given a chance, I would also screen this child for autism and ADHD because these disorders are closely linked to conduct disorder. Ethical consideration is would consider when handling is the case is autonomy. I would ensure that the wishes of the patient’s mother are adhered to because she is the legal guardian of the patient.

Case Formulation and Treatment Plan: 

As noted in the diagnostic impression, the patient has conduct disorder. Therefore, I would recommend that she start a cognitive behavior therapy treatment to help her manage their behavior. Sukhodolsky et al. (2016) noted that CBT can be used to help children and adolescents manage their anger, aggression, and irritability. CBT can also be used to treat social anxiety and IED.

I would recommend that the child start a 30-minute CBT session a week for the next eight weeks. A health promotion would focus on the patient’s mother. I would educate her on how to handle the child. I would also urge her to ensure that the patient comes for therapy as prescribed. The patient would come for follow-up treatment every two weeks.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). American Psychiatric Publishing.

Fanning, J. R., Coleman, M., Lee, R., & Coccaro, E. F. (2019). Subtypes of aggression in intermittent explosive disorder. Journal of Psychiatric Research, 109, 164–172. https://doi.org/10.1016/j.jpsychires.2018.10.013

Fanti, K. A., Kyranides, M. N., Lordos, A., Colins, O. F., & Andershed, H. (2018). Unique and interactive associations of callous-unemotional traits, impulsivity and grandiosity with child and adolescent conduct disorder symptoms. Journal of Psychopathology and Behavioral Assessment, 40(1), 40-49. https://doi.org/10.1007/s10862-018-9655-9

Koyuncu, A., İnce, E., Ertekin, E., & Tükel, R. (2019). Comorbidity in social anxiety disorder: Diagnostic and therapeutic challenges. Drugs in Context, 8. https://dx.doi.org/10.7573%2Fdic.212573

Sukhodolsky, D. G., Smith, S. D., McCauley, S. A., Ibrahim, K., & Piasecka, J. B. (2016). Behavioral interventions for anger, irritability, and aggression in children and adolescents. Journal of Child And Adolescent Psychopharmacology, 26(1), 58–64. https://doi.org/10.1089/cap.2015.0120

Ward, C. L., Wessels, I. M., Lachman, J. M., Hutchings, J., Cluver, L. D., Kassanjee, R., … & Gardner, F. (2020). Parenting for lifelong health for young children: A randomized controlled trial of a parenting program in South Africa to prevent harsh parenting and child conduct problems. Journal of Child Psychology And Psychiatry, 61(4), 503-512. https://acamh.onlinelibrary.wiley.com/doi/full/10.1111/jcpp.13129

Alternative Expert Answer

SOAP Note for Major Depressive Disorder

Subjective:

CC (chief complaint): “I have had depression for many years.”

HPI: MM is a 24-years-old female of white origin who came to group therapy complaining of depression since the age of 13. She noted that she started experiencing relational and emotional difficulties with her family, especially her sisters.

She also noted that she sometimes has a depressed mood and feels low. She reported a loss of interest in her job which she loved before. Associated symptoms include fatigue, weakness, and unintended weight loss. Her depression severity is 7/10.

Past Psychiatric History:

• General Statement: Her first treatment for depression was at the age of 13.
• Caregivers: No caregivers.
• Hospitalizations: No hospitalization. She also denies suicidal and homicidal thoughts.
• Medication trials: No medical trials.
• Psychotherapy or Previous Psychiatric Diagnosis: She was diagnosed with MDD at the age of 13.

Substance Current Use and History: Denies tobacco, cocaine, heroin, alcohol, or any drug use.

Family Psychiatric/Substance Use History: No family history of substance uses or mental health problems.

Psychosocial History: She was born and raised in New York City by her parents until the age of 12. Her parents divorced when she was 13 and moved to Aurora, Colorado with her mother. She has three siblings, two sisters and a brother. She is the second born in the family. She is not married and single. She has no children. She lives with her alone in school. She is pursuing her degree in economics. She likes football but has not gone to training for the last two months. She does not work. She reports no history of violence, trauma, or legal issues.

Medical History: No underlying mental problem.

• Current Medications: No medications.
• Allergies: No allergies.
• Reproductive Hx: She is sexually active. No reproductive abnormalities.

ROS

• GENERAL: Reports fatigue, weakness, and unintended weight loss.
• HEENT: Non-contributory.
• SKIN: She denies dryness, itching, or rashes.
• CARDIOVASCULAR: No chest discomfort, pain, or swelling
• RESPIRATORY: No shortness of breath.
• GASTROINTESTINAL: No nausea, abdominal pain, or diarrhea.
• GENITOURINARY: No UTI or burning or urination.
• NEUROLOGICAL: No neurological disorders.
• MUSCULOSKELETAL: No joint or muscle abnormalities.
• HEMATOLOGIC: No bruising.
• LYMPHATICS: No history of splenectomy.
• ENDOCRINOLOGIC: No endocrinologic abnormalities.

Objective:

Physical exam:

Vital Signs: T 36.5, HR 78, BP 111/90, Ht. 5’5 Wt. 56kgs, RR 18.

• HEENT: Head: Non-contributory.
• Skin: Warm, no rash, and dry.
• CV: No murmurs, chest clear, no chest swelling. Regular heart rate and rhythm.
• Respiratory: No distress while breathing. No wheezes.

Diagnostic results:

The Hopkins Symptoms Checklist with 25 Items (HSCL-25): HSCL-25 is one of the tools used to screen for depression. Skogen et al. (2017) note that the tool can help a mental health professional screen for anxiety or depression. The HSCL-25 results show that the patient has depression.

Assessment:

Mental Status Examination: She is dressed inappropriately. She has good eye contact, is on the verge of tears, appears calm, relates well. Speech volume and rate are standard. She was shaking when talking about her emotional feelings. She denies any homicidal or suicidal thoughts. She is A&O x4. She reports poor concentration. Her memory is intact. Her thoughts are intact. She denies hallucinations, delusions, or paranoid thoughts. She reports low mood and affect.

Differential Diagnoses: 

1. Recurrent MDD DSM-5 (296.99 (F34.8)
2. MDD DSM-5 296.33 (F33.2)
3. Bipolar II Disorder DSM-5 (296.89 (F31. 81)

The primary diagnosis is severe recurrent MDD. Recurrent MDD is associated with repeated depression episodes without reports of independent episodes of mania, increased energy, or mood elevation (Yan et al., 2019). Individuals with recurrent MDD have had at least a single depressive symptom for a minimum of two weeks.

The patient is said to have recurrent MDD because she has experienced repeated episodes of MDD. The second disorder is MDD. The patient reports a depressed mood, lack of interest in things she loved before, fatigue, weakness, and unintended weight loss which are all symptoms of MDD (Bot et al., 2019).

However, the MDD is not initial because the patient has experienced the symptoms since age 13. The last diagnosis is bipolar II disorder. The disorder causes depressive episodes and that is why it is part of the diagnosis (McKnight et al., 2017). However, it is a secondary disorder because it causes hypomania and the patient does not have hypomania (APA, 2013).

Reflections:

I agree with the preceptor’s diagnosis. She also noted that the patient has recurrent MDD which is correct. I have learned from this case that recurrent MDD is hard to diagnose. If I was given the chance again, I would have included MRI as part of the diagnostic studies to improve my diagnosis. In terms of ethical considerations, I would consider our professional boundaries.

I would ensure that we maintain a professional relationship. Another ethical issue is veracity (Hsin & Torous, 2016). I will ensure that I use facts to made decision.

Case Formulation and Treatment Plan:

The patient has recurrent MDD. She should start Zoloft 25mg orally daily in addition to the CBT group therapy she is currently undergoing. Duffy et al. (2019) reported that Zoloft is an effective treatment for depression. Hence, combining Zoloft and CBT group therapy can improve her depressive symptoms.

 References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Author.

Bot, M., Brouwer, I. A., Roca, M., Kohls, E., Penninx, B., Watkins, E., van Grootheest, G., Cabout, M., Hegerl, U., Gili, M., Owens, M., Visser, M., & MooDFOOD Prevention Trial Investigators (2019). Effect of multinutrient supplementation and food-related behavioral activation therapy on prevention of major depressive disorder among overweight or obese adults with subsyndromal depressive symptoms: The MooDFOOD randomized clinical trial. JAMA, 321(9), 858–868. https://doi.org/10.1001/jama.2019.0556

Duffy, L., Lewis, G., Ades, A., Araya, R., Bone, J., Brabyn, S., … & Woodhouse, R. (2019). Antidepressant treatment with sertraline for adults with depressive symptoms in primary care: the PANDA research programme including RCT. Programme Grants for Applied Research, 7(10), 108. https://doi.org/10.3310/pgfar07100

Hsin, H., & Torous, J. (2016). Ethical issues in the treatment of depression. Focus (American Psychiatric Publishing), 14(2), 214–218. https://doi.org/10.1176/appi.focus.20150046

McKnight, R. F., Bilderbeck, A. C., Miklowitz, D. J., Hinds, C., Goodwin, G. M., & Geddes, J. R. (2017). Longitudinal mood monitoring in bipolar disorder: course of illness as revealed through a short messaging service. Journal of Affective Disorders, 223, 139-145. https://doi.org/10.1016/j.jad.2017.07.029

Skogen, J. C., Øverland, S., Smith, O. R., & Aarø, L. E. (2017). The factor structure of the Hopkins Symptoms Checklist (HSCL-25) in a student population: a cautionary tale. Scandinavian Journal Of Public Health, 45(4), 357-365. https://doi.org/10.1177%2F1403494817700287

Yan, C. G., Chen, X., Li, L., Castellanos, F. X., Bai, T. J., Bo, Q. J., … & Zang, Y. F. (2019). Reduced default mode network functional connectivity in patients with recurrent major depressive disorder. Proceedings of the National Academy of Sciences, 116(18), 9078-9083. https://doi.org/10.1073/pnas.1900390116

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