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.

• 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 for an impulse control or conduct disorder 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.

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

• Dress professionally with a lab coat 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?

Submit your Video and Comprehensive Psychiatric Evaluation Note Assignment. You must submit two files for the evaluation note, including a Word document and scanned pdf/images of each page that is initialed and signed by your Preceptor.

Subjective:

CC (chief complaint): School is requiring a psychiatric evaluation because patient was a “danger to herself”.

HPI: C.F. is a 16-year-old Caucasian female who presented to this outpatient psychiatric center for further psychiatric evaluation required by school because she appeared to be a danger to herself. Patient reports suffering with depression and anxiety for years. However, it has gotten worst lately. Patient went to school on 09/28/2021 and reports she could not stop crying. She was evaluated by her school counselor/therapist who determined patient needed further psychiatric evaluation due to safety concern. Patient went to a different facility for psychiatric evaluation whom she felt was incompetent and therefore, decided to come here instead. Upon arrival to facility patient admitted to having current suicidal ideation (SI) with no plan or intent now. However, stated that due to her impulsive nature she could act on her SI. Nonetheless, patient reported she can keep herself safe for now because of the recent mental breakdown she had that usually leads to feeling content afterwards. Patient also reports she could talk to her parents if the thoughts got worse. Patient reports a history of 3 suicide attempts. Her first attempt was at age 7-8 y/o when she jumped off the roof her 2-story house after writing her will. The second attempt was in 8^th grade and the third in freshman year. For either of the last two attempts patient does not recall the method, it was either by cutting herself or overdosing on pills. According to patient neither of the 3 suicide attempts caused any injury or required treatment. Patient denies any history of homicidal ideation (HI) or violence towards people/property. Patient does report history of self-injurious behavior (SIB) by cutting or scratching, which started in 6^th grade. Most recent SIB was with fire a week prior to this admission. Patient reports she was messing around with fire but did not burn herself as she was able to distract herself. Patient reports being anxious all the time, which gets worse in social situations and school. Patient reports history of panic attacks during which patient has trouble breathing, body shuts down, cannot think, or speak. However, afterwards she either becomes non-responsiveness or aggressive. Patient reports her last panic attack was over the summer. Patient

reports experiencing a lot of online sexual harassment. Patient reports that she has been sexually involved in social media and has been groomed by older men (on the internet) over the years. Patient has this feeling of guilt and shame, and she blames herself for the actions of men on social media that have groomed her and sexually harassed her over the years. Patient reports she had been sexting and thinks her inappropriate pictures and videos are probably floating around on the internet. Reports being blackmailed to send more inappropriate pictures and videos with a threat to circulate her previously sent sextings. Patient denies reporting this to authorities. Patient reports constant racing and intrusive thoughts mostly sexual in nature. Patient reports having difficulty keeping friends because her thoughts about these friends often quickly turn sexual, which perhaps the friends catch and leave her. Patient reports distancing from family because her thoughts regarding family members could potentially and eventually automatically become sexual in nature. Academically patient has As and Bs in all classes except for Math which she is failing. However, patient reports no motivation left for school or work since she has been unfriended by all her friends even on social media. Reports difficulty falling and staying asleep, sleeps 5 hours with interruptions, wakes up several times. Patient also reports poor appetite, but denies restricting, binging, purging.

Important information for writing discussion questions and participation

Welcome to class

Hello class and welcome to the class and I will be your instructor for this course. This is a -week course and requires a lot of time commitment, organization, and a high level of dedication. Please use the class syllabus to guide you through all the assignments required for the course. I have also attached the classroom policies to this announcement to know your expectations for this course. Please review this document carefully and ask me any questions if you do. You could email me at any time or send me a message via the “message” icon in halo if you need to contact me. I check my email regularly, so you should get a response within 24 hours. If you have not heard from me within 24 hours and need to contact me urgently, please send a follow up text to

I strongly encourage that you do not wait until the very last minute to complete your assignments. Your assignments in weeks 4 and 5 require early planning as you would need to present a teaching plan and interview a community health provider. I advise you look at the requirements for these assignments at the beginning of the course and plan accordingly. I have posted the YouTube link that explains all the class assignments in detail. It is required that you watch this 32-minute video as the assignments from week 3 through 5 require that you follow the instructions to the letter to succeed. Failure to complete these assignments according to instructions might lead to a zero. After watching the video, please schedule a one-on-one with me to discuss your topic for your project by the second week of class. Use this link to schedule a 15-minute session. Please, call me at the time of your appointment on my number. Please note that I will NOT call you.

Please, be advised I do NOT accept any assignments by email. If you are having technical issues with uploading an assignment, contact the technical department and inform me of the issue. If you have any issues that would prevent you from getting your assignments to me by the deadline, please inform me to request a possible extension. Note that working fulltime or overtime is no excuse for late assignments. There is a 5%-point deduction for every day your assignment is late. This only applies to approved extensions. Late assignments will not be accepted.

If you think you would be needing accommodations due to any reasons, please contact the appropriate department to request accommodations.

Plagiarism is highly prohibited. Please ensure you are citing your sources correctly using APA 7th edition. All assignments including discussion posts should be formatted in APA with the appropriate spacing, font, margin, and indents. Any papers not well formatted would be returned back to you, hence, I advise you review APA formatting style. I have attached a sample paper in APA format and will also post sample discussion responses in subsequent announcements.

Your initial discussion post should be a minimum of 200 words and response posts should be a minimum of 150 words. Be advised that I grade based on quality and not necessarily the number of words you post. A minimum of TWO references should be used for your initial post. For your response post, you do not need references as personal experiences would count as response posts. If you however cite anything from the literature for your response post, it is required that you cite your reference. You should include a minimum of THREE references for papers in this course. Please note that references should be no more than 5 years old except recommended as a resource for the class. Furthermore, for each discussion board question, you need ONE initial substantive response and TWO substantive responses to either your classmates or your instructor for a total of THREE responses. There are TWO discussion questions each week, hence, you need a total minimum of SIX discussion posts for each week. I usually post a discussion question each week. You could also respond to these as it would count towards your required SIX discussion posts for the week.

I understand this is a lot of information to cover in 5 weeks, however, the Bible says in Philippians 4:13 that we can do all things through Christ that strengthens us. Even in times like this, we are encouraged by God’s word that we have that ability in us to succeed with His strength. I pray that each and every one of you receives strength for this course and life generally as we navigate through this pandemic that is shaking our world today. Relax and enjoy the course!

Hi Class,

Please read through the following information on writing a Discussion question response and participation posts.

Contact me if you have any questions.

Important information on Writing a Discussion Question

• Your response needs to be a minimum of 150 words (not including your list of references)
• There needs to be at least TWO references with ONE being a peer reviewed professional journal article.
• Include in-text citations in your response
• Do not include quotes—instead summarize and paraphrase the information
• Follow APA-7th edition
• Points will be deducted if the above is not followed

Participation –replies to your classmates or instructor

• A minimum of 6 responses per week, on at least 3 days of the week.
• Each response needs at least ONE reference with citations—best if it is a peer reviewed journal article
• Each response needs to be at least 75 words in length (does not include your list of references)
• Responses need to be substantive by bringing information to the discussion or further enhance the discussion. Responses of “I agree” or “great post” does not count for the word count.
• Follow APA 7th edition
• Points will be deducted if the above is not followed

• Remember to use and follow APA-7th edition for all weekly assignments, discussion questions, and participation points.
• Here are some helpful links
• The is a great resource

Past Psychiatric History:

• General Statement: C.F. is a 16 y/o Caucasian female with h/o depression and anxiety since elementary age and relates most of it to her hypersexuality and actions such inappropriate use of social media, being groomed by men on social media over the years. Patient also has body image issues and difficulty maintaining friendships.
• Caregivers (if applicable): N/A.
• Hospitalizations: Denies
• Medication trials: Denies. However, family has had success with Zoloft and Lexapro. Family history of suicidality (genetic sensitivity) with Prozac.
• Psychotherapy or Previous Psychiatric Diagnosis: Sees a therapist once per week.

Substance Current Use and History: History of occasional alcohol use. None currently.

Family Psychiatric/Substance Use History: Not specific, but both parents suffer with depression and anxiety, Father has anger issues.

Psychosocial History: Patient is a 16 y/o single female who lives at home with parents and 2 older sisters ages 18 (currently away for college) and 21-year-old patient is bisexual and reports interest in both boys and girls. She works as a receptionist at a local hair salon. Currently attending 11th grade at local high school. Not in any special program in school. Would like to be in a special program especially the ombudsmen program. Anxiety worsens in social situations and school.

Medical History:

• Current medical problems: Scoliosis (mild)
• Current Medications: None
• Allergies: No known food, drug, plant, animal, or medication allergies

• Reproductive Hx: Single, bisexual, regular periods

ROS:

• GENERAL: Alert and oriented, groomed, appropriately dressed for the season and occasion. However, wearing dramatic eye make-up. Appears younger for age.
• HEENT: no issues
• SKIN: no issues
• CARDIOVASCULAR: no issues
• RESPIRATORY: no issues
• GASTROINTESTINAL: no issues
• GENITOURINARY: no issues
• NEUROLOGICAL: no issues
• MUSCULOSKELETAL: mild scoliosis, constant pain in both knees and back, wears corset for support.
• HEMATOLOGIC: no issues
• LYMPHATICS: no issues
• ENDOCRINOLOGIC: no issues

Objective:

Physical exam:

Height – 151.1 cm (4’9”)

Weight – 41.6 kg (91.7 lb)

BMI – 19.8

Diagnostic results: N/A

Assessment:

Mental Status Examination:

Appearance:  Client is well-kempt and appropriately dressed for age, weather, and occasion. Appears younger than stated age.

Eye contact: Hesitant

Speech: normal rhythm and volume

Behavior: Cooperative, fidgety

Psychomotor: Restless/fidgety

Mood: depressed, anxious

Affect: congruent with mood

Thought Process: racing thoughts, but organized

Thought Content:  No delusions, passive suicidal and self-harm ideation. No Homicidal ideation.

Perception:  No reaction to external or internal stimuli.

Attention/ Concentration: Able to concentrate and participate in the assessment as expected

Cognition:  Alert, oriented X 4.

Memory:  Short-term and long-term memory are grossly intact.

Insight: limited

Judgment: limited

Fund of Knowledge:  Average.

Intelligence:  Average.

Differential Diagnoses:

Major Depressive Disorder (severe) without psychosis

The DSM V diagnostic criteria for MDD without psychosis include at least five of the following clinical features, with at least one of the features being a depressed mood or diminished interest in activities (Mullen, 2018). The five clinical features must have been present for at least two weeks (APA, 2013). The other symptoms include Appetite disturbance; Weight changes; Sleep disturbance; Fatigue or loss of energy; Psychomotor agitation or retardation; Feelings of guilt or worthlessness; A reduced ability to think or concentrate with indecisiveness; and recurrent thoughts of death or suicidal ideations without a specific plan, or a suicide attempt (APA, 2013). Pertinent symptoms supporting MDD as a differential diagnosis include the patient’s report of worsening depression with tearfulness, lack of motivation for school, sleep disturbances, and reduced appetite. In addition, the patient has feelings of guilt and shame about her actions. She engages in self-harm behavior and has suicidal ideations and a history of several suicide attempts, consistent with MDD.

Generalized Anxiety Disorder (GAD)

GAD manifests with excessive anxiety and worries about various events and activities. The anxiety and worry are usually difficult to control (APA, 2013). The anxiety and worry occur with at least three symptoms, which occur more days for at least six months. The accompanying symptoms include restlessness, easy fatigue, irritability, concentration difficulties, muscle tension, and sleep disturbance (APA, 2013). Suicidal ideation and attempts may occur with GAD. GAD is a differential diagnosis based on the client’s history of getting anxiety, which worsens in social situations and school and experiencing racing and intrusive thoughts. She also experiences sleep disturbances which are common in GAD. Panic attacks can be attributed to anxiety. Besides, she reports having suicidal ideations, which can occur in GAD. However, the patient’s symptoms do not fully meet the diagnostic criteria for GAD.

Bipolar II Disorder

Bipolar disorder manifests with episodes of hypomania and major depression. Hypomanic episodes last about four days (Bobo, 2017). They are characterized by a mild elevated mood with an increased sense of psychological wellbeing and happiniess not associated with other events (APA, 2013). The hypomanic episodes also present with: An infkated self-esteem, reduced need for sleep, and over-involvement in pleasurable activities with painful consequences (APA, 2013). Pertinent positive findings supporting Bipolar II disorder depression symptoms, racing and intrusive thoughts, and engaging in pleasurable activities with adverse consequences, such as sending inappropriate pictures and videos on the internet. However, Bipolar II disorder is an unlikely diagnosis since the patient has no history of having episodes of elevated mood.

Borderline Personality Disorder (BPD)

BPD is characterized by an odd and eccentric personality. The diagnostic criteria include presence of: Unstable interpersonal relationships; Self-image problem; Trying too much to avoid being abandoned; Impulsive behavior; Recurrent self-mutilating behavior; Chronic feelings of emptiness; and entering into sexual liaisons (APA, 2013). BPD is a differential diagnosis based on the patient’s history of impulsivity, difficulties maintaining friends, recurrent self-mutilating behavior through cutting, burning, and suicide, and entering sexual liaisons through sexting and sending inappropriate behaviors

Impulse Control Disorder (ICD)

Persons with ICD typically present with a history of engaging in pleasurable or hedonic behaviors, such as gambling, shopping, or sex. The behaviors are conducted repetitively, excessively, or compulsively, to a level that interfere with major areas of life functioning (Fariba & Gokarakonda, 2021).  ICD manifest with a failure to resist an impulse, drive, or temptation to engage in an act that is harmful to the person or to others (Fariba & Gokarakonda, 2021). ICD is a differential diagnosis based on the patient’s report of engaging in hedonic behaviors such as sexting and sending inappropriate pictures and videos on the internet. However, it is an unlikely primary diagnosis since the patient does not experience the behavior as an impulse.

Reflections:

If I were to assess the patient again, I would utilize depression screening tools such as the Patient Health Questionnaire-9 (PHQ-9). The PHQ-9 would help assess the severity of the patient’s depression and confirm the differential diagnosis of MDD (Mullen, 2018). I would also use the Generalized Anxiety Disorder scale (GAD-7), a diagnostic self-report scale used to screen, diagnose, and assess the severity of anxiety disorders (Jordan et al., 2017). The screening tools would help in confirming or ruling out the differential diagnoses.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub.

Bobo, W. V. (2017, October). The diagnosis and management of bipolar I and II disorders: clinical practice update. In Mayo Clinic Proceedings (Vol. 92, No. 10, pp. 1532-1551). Elsevier. https://doi.org/10.1016/j.mayocp.2017.06.022

Fariba, K., & Gokarakonda, S. B. (2021). Impulse Control Disorders. StatPearls [Internet].

Jordan, P., Shedden-Mora, M. C., & Löwe, B. (2017). Psychometric analysis of the Generalized Anxiety Disorder scale (GAD-7) in primary care using modern item response theory. PloS one, 12(8), e0182162. https://doi.org/10.1371/journal.pone.0182162

Mullen, S. (2018). Major depressive disorder in children and adolescents. The mental health clinician, 8(6), 275–283. https://doi.org/10.9740/mhc.2018.11.275

To submit your completed Assignment for review and grading, do the following:

• Please save your Assignment using the naming convention “WK7Assgn2+last name+first initial.(extension)” as the name.
• Click the Week 7 Assignment 2 Rubric to review the Grading Criteria for the Assignment.
• Click the Week 7 Assignment 2 link. You will also be able to “View Rubric” for grading criteria from this area.
• Next, from the Attach File area, click on the Browse My Computer button. Find the document you saved as “WK7Assgn2+last name+first initial.(extension)” and click Open.
• If applicable: From the Plagiarism Tools area, click the checkbox for I agree to submit my paper(s) to the Global Reference Database.
• Click on the Submit button to complete your submission.