______________________________________________________________________________ 00:00:00BEGIN TRANSCRIPT: 00:00:00[sil.] 00:00:15OFF CAMERA So, you told your supervisor you were having difficulty with concentration, and then it was your supervisor who set up this appointment, right, is it? 00:00:25HAROLD Yeah, I, I work at this large architectural engineering firm and it's all great. Except, they've accelerated the deadlines now and it just puts a lot of pressure on. And I, I just can't concentrate. I mean, everyone else is, doesn't have a problem with it. But, but I just, I just can't seem to be able to do the same job they're doing. 00:00:50OFF CAMERA Okay, tell me about your problem with concentration. 00:00:55HAROLD Well, um, you know it's just... Perfect example is, is they wanted me to design um, air ducts. 00:01:05OFF CAMERA Right. 00:01:05HAROLD Air ducts, simple. But I designed them through solid wall, a fire wall, and a supporting wall and I didn't even realize what I was doing. 00:01:15OFF CAMERA Uh-huh. 00:01:15HAROLD You know, I mean, um, I'm making silly mistakes like that because, another time we had these windows, we already bought them, design, beautiful, they're going to be in this entire building. 00:01:30OFF CAMERA Right. 00:01:30HAROLD Every floor. Well, I drew the window opening way too small. Now, I mean, if that would have gone ahead, it would have cost millions. I just, it's, it's just silly things like that. 00:01:45OFF CAMERA Uh-huh, is this a new kind of problem for you? 00:01:45HAROLD Well, I mean, I didn't seem to have a problem when everything was relaxed, and the deadlines were normal. 00:01:50OFF CAMERA Right. 00:01:55HAROLD I could do the job. Everything was fine. But now we're on these, these ridiculously tight deadlines and, and I just, can't seem to do it. Everyone else can. It's, there's not a problem for them. And I end up like I'm not pulling my weight. 00:02:10OFF CAMERA Uh-huh. 00:02:10HAROLD And they think that and it's true, I'm not. 00:02:10OFF CAMERA Now did you have these, uh, similar kind of problems back in school? 00:02:15HAROLD Well, yeah, I mean, in school everyone would go to the library to cram for big exams, so, I mean. 00:02:20OFF CAMERA Right. 00:02:20HAROLD That was a normal thing. And, yeah, I'd go but I'd end up looking out the window. Look it's snowing, oh, it's spring time. I'll go for a walk. And, and if someone is whispering in a library well, I have to go to the other side. All my friends could study anywhere. 00:02:35OFF CAMERA Uh-huh, but, what other kind of difficulties do you seem to have? 00:02:40HAROLD Well, at the job we have, these uh, lectures, you know. 00:02:45OFF CAMERA Right. 00:02:45HAROLD We'd get together, it's groups. This is the lectures by the chief of the department gets together with all the architects and engineers and he talks about the mission of the day. What we're trying to work for, our goals. 00:02:55OFF CAMERA Right. 00:03:00HAROLD Do I listen? I'm thinking, maybe, my dog needs a bath. Or what am I going to have for lunch? Or, you know, anything other than what he's saying. 00:03:05OFF CAMERA Mm-hmm. 00:03:10HAROLD And because of that, you know, it's not a good idea. 00:03:15OFF CAMERA So, so, is it difficult to sit and listen? 00:03:20HAROLD Yeah, I mean, okay, we were suppose to be designing this other, on top of this penthouse, this, kind of, a patio, party area. 00:03:30OFF CAMERA Right. 00:03:30HAROLD And the gutters around it just to make sure everything was very comfortable for everyone. Well, I got up there and I'm designing and the gutters are here, and no, wait a minute, there's Italian, tile floor. Doesn't look like it's tilted the correct way. So I started studying that and there were already two people assigned to study that. To fix that problem, not me. 00:03:50OFF CAMERA Mm-hmm. 00:03:55HAROLD I got in a lot of trouble for that one. 00:03:55OFF CAMERA Do you have any problems organizing? 00:04:00HAROLD At home or the office? 00:04:00OFF CAMERA Uh, either. 00:04:05HAROLD I'm a bit of a mess. I mean, and I'm messy. I will forget my shoes, my socks, my phone, my jacket, I, I can't find them. I'm not that organized. And I have a calendar. One of my coworkers, actually bought me a calendar to motivate me. 00:04:20OFF CAMERA Yeah. 00:04:25HAROLD To get more organized. So, I started writing down all the important dates and events, but then do I ever look at that calendar? No, I don't. So, it's a complete waste of time. 00:04:35OFF CAMERA What about problems paying bills? 00:04:40HAROLD Bills, I mean, yeah they get paid. After two or three times of the threatening calls or letters. And then I have to pay the penalties. 00:04:50OFF CAMERA Hmm, what about hyperactivity? 00:04:50HAROLD You know, I mean, I'm, sometimes I'm a little more uncomfortable in a chair or you know. But I don't think that's that big a deal. I mean, I used to be a lot worse. I mean, uh, there was a time when I was in school, I would get marked down for citizenship because I never raised my hand and I talked out of class and, and I just, couldn't seem to stay focused. But I'm a lot better now. 00:05:20OFF CAMERA Mm-hmm, were you ever um, treated with medications or behavioral therapies for ADHD? 00:05:25HAROLD No, no. My mother threatened that one time, but I was never evaluated. Never went, uh, I'm kind of amazed she never just dragged me into a doctor's office, but she never did. 00:05:40OFF CAMERA Do you drink any caffeinated drinks? 00:05:45HAROLD Coffee, soda, you know, once in a while. But when I was a kid, my mother said no caffeine, no sugar, cause you'll climb the walls. I was already doing it anyway and so she, I uh, once and a while I'll have a little caffeine now and it kind of helps me focus a little but, sugar, I stay away from that. It's just not a good idea. 00:06:05END TRANSCRIPT Week (enter week #): (Enter assignment title) Student Name College of Nursing-PMHNP, Walden University NRNP 6635: Psychopathology and Diagnostic Reasoning Faculty Name Assignment Due Date NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template Subjective: CC (chief complaint): HPI: Past Psychiatric History: • • • • • General Statement: Caregivers (if applicable): Hospitalizations: Medication trials: Psychotherapy or Previous Psychiatric Diagnosis: Substance Current Use and History: Family Psychiatric/Substance Use History: Psychosocial History: Medical History: • • • Current Medications: Allergies: Reproductive Hx: ROS: • • • • • • • • • • • • GENERAL: HEENT: SKIN: CARDIOVASCULAR: RESPIRATORY: GASTROINTESTINAL: GENITOURINARY: NEUROLOGICAL: MUSCULOSKELETAL: HEMATOLOGIC: LYMPHATICS: ENDOCRINOLOGIC: Objective: Physical exam: if applicable © 2021 Walden University Page 2 of 3 NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template Diagnostic results: Assessment: Mental Status Examination: Differential Diagnoses: Reflections: References © 2021 Walden University Page 3 of 3 NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Exemplar INSTRUCTIONS ON HOW TO USE EXEMPLAR AND TEMPLATE—READ CAREFULLY If you are struggling with the format or remembering what to include, follow the Comprehensive Psychiatric Evaluation Template AND the Rubric as your guide. It is also helpful to review the rubric in detail in order not to lose points unnecessarily because you missed something required. Below highlights by category are taken directly from the grading rubric for the assignment in Weeks 4–10. After reviewing the full details of the rubric, you can use it as a guide. 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 Read rating descriptions to see the grading standards! 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. Read rating descriptions to see the grading standards! 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-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 criticalthinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case. Read rating descriptions to see the grading standards! Reflect on this case. Include: Discuss what you learned and what you might do differently. Also include in your reflection a discussion related to legal/ethical © 2021 Walden University Page 1 of 6 NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Exemplar 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.). (The comprehensive evaluation is typically the initial new patient evaluation. You will practice writing this type of note in this course. You will be ruling out other mental illnesses so often you will write up what symptoms are present and what symptoms are not present from illnesses to demonstrate you have indeed assessed for all illnesses which could be impacting your patient. For example, anxiety symptoms, depressive symptoms, bipolar symptoms, psychosis symptoms, substance use, etc.) EXEMPLAR BEGINS HERE CC (chief complaint): A brief statement identifying why the patient is here. This statement is verbatim of the patient’s own words about why presenting for assessment. For a patient with dementia or other cognitive deficits, this statement can be obtained from a family member. HPI: Begin this section with patient’s initials, age, race, gender, purpose of evaluation, current medication and referral reason. For example: N.M. is a 34-year-old Asian male presents for psychiatric evaluation for anxiety. He is currently prescribed sertraline which he finds ineffective. His PCP referred him for evaluation and treatment. Or P.H., a 16-year-old Hispanic female, presents for psychiatric evaluation for concentration difficulty. She is not currently prescribed psychotropic medications. She is referred by her therapist for medication evaluation and treatment. Then, this section continues with the symptom analysis for your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. First what is bringing the patient to your evaluation. Then, include a PSYCHIATRIC REVIEW OF SYMPTOMS. The symptoms onset, duration, frequency, severity, and impact. Your description here will guide your differential diagnoses. You are seeking symptoms that may align with many DSM-5-TR diagnoses, narrowing to what aligns with diagnostic criteria for mental health and substance use disorders. Past Psychiatric History: This section documents the patient’s past treatments. Use the mnemonic Go Cha MP. © 2021 Walden University Page 2 of 6 NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Exemplar General Statement: Typically, this is a statement of the patients first treatment experience. For example: The patient entered treatment at the age of 10 with counseling for depression during her parents’ divorce. OR The patient entered treatment for detox at age 26 after abusing alcohol since age 13. Caregivers are listed if applicable. Hospitalizations: How many hospitalizations? When and where was last hospitalization? How many detox? How many residential treatments? When and where was last detox/residential treatment? Any history of suicidal or homicidal behaviors? Any history of self-harm behaviors? Medication trials: What are the previous psychotropic medications the patient has tried and what was their reaction? Effective, Not Effective, Adverse Reaction? Some examples: Haloperidol (dystonic reaction), risperidone (hyperprolactinemia), olanzapine (effective, insurance wouldn’t pay for it) Psychotherapy or Previous Psychiatric Diagnosis: This section can be completed one of two ways depending on what you want to capture to support the evaluation. First, does the patient know what type? Did they find psychotherapy helpful or not? Why? Second, what are the previous diagnosis for the client noted from previous treatments and other providers. Thirdly, you could document both. Substance Use History: This section contains any history or current use of caffeine, nicotine, illicit substance (including marijuana), and alcohol. Include the daily amount of use and last known use. Include type of use such as inhales, snorts, IV, etc. Include any histories of withdrawal complications from tremors, Delirium Tremens, or seizures. Family Psychiatric/Substance Use History: This section contains any family history of psychiatric illness, substance use illnesses, and family suicides. You may choose to use a genogram to depict this information. Be sure to include a reader’s key to your genogram or write up in narrative form. Social History: This section may be lengthy if completing an evaluation for psychotherapy or shorter if completing an evaluation for psychopharmacology. However, at a minimum, please include: Where patient was born, who raised the patient Number of brothers/sisters (what order is the patient within siblings) Who the patient currently lives with in a home? Are they single, married, divorced, widowed? How many children? Educational Level Hobbies: Work History: currently working/profession, disabled, unemployed, retired? Legal history: past hx, any current issues? © 2021 Walden University Page 3 of 6 NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Exemplar Trauma history: Any childhood or adult history of trauma? Violence Hx: Concern or issues about safety (personal, home, community, sexual (current & historical) Medical History: This section contains any illnesses, surgeries, include any hx of seizures, head injuries. Current Medications: Include dosage, frequency, length of time used, and reason for use. Also include OTC or homeopathic products. Allergies: Include medication, food, and environmental allergies separately. Provide a description of what the allergy is (e.g., angioedema, anaphylaxis). This will help determine a true reaction vs. intolerance. Reproductive Hx: Menstrual history (date of LMP), Pregnant (yes or no), Nursing/lactating (yes or no), contraceptive use (method used), types of intercourse: oral, anal, vaginal, other, any sexual concerns ROS: Cover all body systems that may help you include or rule out a differential diagnosis. Please note: THIS IS DIFFERENT from a physical examination! You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe. Example of Complete ROS: GENERAL: No weight loss, fever, chills, weakness, or fatigue. HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat. SKIN: No rash or itching. CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema. RESPIRATORY: No shortness of breath, cough, or sputum. GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood. GENITOURINARY: Burning on urination, urgency, hesitancy, odor, odd color NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control. © 2021 Walden University Page 4 of 6 NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Exemplar MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness. HEMATOLOGIC: No anemia, bleeding, or bruising. LYMPHATICS: No enlarged nodes. No history of splenectomy. ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia. Physical exam (If applicable and if you have opportunity to perform—document if exam is completed by PCP): From head to toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head-to-toe format i.e., General: Head: EENT: etc. Diagnostic results: Include any labs, X-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines). Assessment Mental Status Examination: For the purposes of your courses, this section must be presented in paragraph form and not use of a checklist! This section you will describe the patient’s appearance, attitude, behavior, mood and affect, speech, thought processes, thought content, perceptions (hallucinations, pseudohallucinations, illusions, etc.)., cognition, insight, judgment, and SI/HI. See an example below. You will modify to include the specifics for your patient on the above elements—DO NOT just copy the example. You may use a preceptor’s way of organizing the information if the MSE is in paragraph form. He is an 8-year-old African American male who looks his stated age. He is cooperative with examiner. He is neatly groomed and clean, dressed appropriately. There is no evidence of any abnormal motor activity. His speech is clear, coherent, normal in volume and tone. His thought process is goal directed and logical. There is no evidence of looseness of association or flight of ideas. His mood is euthymic, and his affect appropriate to his mood. He was smiling at times in an appropriate manner. He denies any auditory or visual hallucinations. There is no evidence of any delusional thinking. He denies any current suicidal or homicidal ideation. Cognitively, he is alert and oriented. His recent and remote memory is intact. His concentration is good. His insight is good. Differential Diagnoses: You must have at least three differentials with supporting evidence. Explain what rules each differential in or out and justify your primary diagnostic impression selection. You will use supporting evidence from the literature to © 2021 Walden University Page 5 of 6 NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Exemplar support your rationale. Include pertinent positives and pertinent negatives for the specific patient case. Also included in this section is the reflection. Reflect on this case and discuss whether or not you agree with your preceptor’s assessment and diagnostic impression of the patient and why or why not. What did you learn from this case? What would you do differently? Also include in your reflection a discussion related to legal/ethical considerations (demonstrating 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.). References (move to begin on next page) You are required to include at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines which relate to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting. © 2021 Walden University Page 6 of 6 
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