Case study
Training Title 151
Name: Daniela Petrov
Gender: female
Age:47 years old
T- 98.8 P- 84 R 20 B/P 132/90 Ht 5’8 Wt 128lbs
Background: Moved to Everett, Washington from Russia with her parents when she was 16 years
old. Currently lives in Boise, Idaho. She has younger 1 brother, 3 older sisters. Denied family
mental health or substance use issues. No history of inpatient detox or rehab denied self-harm hx;
Menses regular. uses condoms for birth control Has fibromyalgia. She works part time cashier at
Save A Lot Grocery Store. Dropped out of high school in 10th grade. Sleeps 5-6 hours on
average, appetite good.
Symptom Media. (Producer). (2018). Training title 151 [Video].
https://go.openathens.net/redirector/waldenu.edu?url=https://video.alexanderstreet.com/watch/training-title-151
· Review this week’s Learning Resources and consider the insights they provide.
· Review the Comprehensive Psychiatric Evaluation template, which you will use to complete this Assignment.
· 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 8
Complete and submit your Comprehensive Psychiatric Evaluation, including your differential diagnosis and critical-thinking process to formulate 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-TR diagnostic criteria for each differential diagnosis and explain what DSM-5-TR 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.).
· NRNP_6635_Week8_Assignment_Rubric
NRNP_6635_Week8_Assignment_Rubric
Criteria
Ratings
Pts
This criterion is linked
to a Learning OutcomeCreate 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
20 to >17.0 pts
Excellent
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.
17 to >15.0 pts
Good
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.
15 to >13.0 pts
Fair
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.
13 to >0 pts
Poor
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.
20 pts
This criterion is linked
to a Learning OutcomeIn 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.
20 to >17.0 pts
Excellent
The response thoroughly and accurately documents the patient’s
physical exam for pertinent systems. Diagnostic tests and their results are
thoroughly and accurately documented.
17 to >15.0 pts
Good
The response accurately documents the patient’s physical exam for
pertinent systems. Diagnostic tests and their results are accurately
documented.
15 to >13.0 pts
Fair
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.
13 to >0 pts
Poor
The response provides incomplete or inaccurate documentation of the
patient’s physical exam. Systems may have been unnecessarily reviewed, or,
objective documentation is missing.
20 pts
This criterion is linked
to a Learning OutcomeIn 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-TR diagnostic
criteria for each differential diagnosis and explain what DSM-5-TR 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.
25 to >22.0 pts
Excellent
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.
22 to >19.0 pts
Good
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.
19 to >17.0 pts
Fair
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.
17 to >0 pts
Poor
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.
25 pts
This criterion is linked
to a Learning OutcomeReflect 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!), social determinates of health, 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.).
10 to >8.0 pts
Excellent
Reflections are thorough, thoughtful, and demonstrate critical
thinking.
8 to >7.0 pts
Good
Reflections demonstrate critical thinking.
7 to >6.0 pts
Fair
Reflections are somewhat general or do not demonstrate critical
thinking.
6 to >0 pts
Poor
Reflections are incomplete, inaccurate, or missing.
10 pts
This criterion is linked
to a Learning OutcomeProvide 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).
15 to >13.0 pts
Excellent
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.
13 to >11.0 pts
Good
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.
11 to >10.0 pts
Fair
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.
10 to >0 pts
Poor
Two or fewer resources are provided to support assessment and
diagnosis decisions. The resources may not be current or evidence based.
15 pts
This criterion is linked
to a Learning OutcomeWritten 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.
5 to >4.0 pts
Excellent
A clear and comprehensive purpose statement, introduction, and
conclusion are provided that delineate all required criteria. …Paragraphs
and sentences follow writing standards for flow, continuity, and clarity.
4 to >3.5 pts
Good
Purpose, introduction, and conclusion of the assignment are stated,
yet they are brief and not descriptive. …Paragraphs and sentences follow
writing standards for flow, continuity, and clarity 80% of the time.
3.5 to >3.0 pts
Fair
Purpose, introduction, and conclusion of the assignment is vague or
off topic. … Paragraphs and sentences follow writing standards for flow,
continuity, and clarity 60%-79% of the time.
3 to >0 pts
Poor
No purpose statement, introduction, or conclusion were provided. …
Paragraphs and sentences follow writing standards for flow, continuity, and
clarity less than 60% of the time.
5 pts
This criterion is linked
to a Learning OutcomeWritten Expression and
Formatting—English writing standards: Correct grammar, mechanics, and
punctuation
5 to >4.0 pts
Excellent
Uses correct grammar, spelling, and punctuation with no errors
4 to >3.0 pts
Good
Contains a few (one or two) grammar, spelling, and punctuation errors
3 to >2.0 pts
Fair
Contains several (three or four) grammar, spelling, and punctuation
errors
2 to >0 pts
Poor
Contains many (≥ five) grammar, spelling, and punctuation errors that
interfere with the reader’s understanding
5 pts
Total Points: 100
