1. Watch the video: https://www.dropbox.com/scl/fi/flpy17420zjc5zxvnlf0b/Screen-Recording-2024-01-06-at-1.16.59-PM.mov?rlkey=z59ridn7g2r4v5nmtfxlqbznp&dl=0
2. Read background information : Name: Mr. Harold Feldman
Gender: male
Age:20 years old
T- 98.4 P- 76 R 18 116/74 Ht 5’6 Wt 120lbs
Background: European-American male. He has two
younger sisters, one with history of ADHD,the other with history of separation
anxiety. His mother has depression; his father has paranoia schizophrenia. He is home for spring break. He has no
previous medical problems. Developmental milestones met as child. Appetite
is inconsistent and it seems he has lost 18lbs since
first going back to school in the fall. He had a short trial of risperidone in
the last six months of high school for mild paranoia. He
stopped the medication after graduation as he could not tolerate due to side effects of over-sedation.
Harold has HS several friends but has not kept in touch
with them since being back home. He has not been showering. Sleeping 14 hrs./
he admits to episodic cannabis use weekly. Allergies
shellfish
3. 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.)
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
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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.
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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.
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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.
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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.
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20 pts
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.
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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.
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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.
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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.
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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.
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20 pts
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 critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
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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.
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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.
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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.
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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.
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25 pts
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!), 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.).
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10 to >8.0 pts Excellent
Reflections are thorough, thoughtful, and demonstrate critical thinking.
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8 to >7.0 pts Good
Reflections demonstrate critical thinking.
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7 to >6.0 pts Fair
Reflections are somewhat general or do not demonstrate critical thinking.
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6 to >0 pts Poor
Reflections are incomplete, inaccurate, or missing.
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10 pts
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).
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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.
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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.
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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.
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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.
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15 pts
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.
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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.
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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.
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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.
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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.
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5 pts
Written Expression and Formatting—English writing standards: Correct grammar, mechanics, and punctuation
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5 to >4.0 pts Excellent
Uses correct grammar, spelling, and punctuation with no errors
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4 to >3.0 pts Good
Contains a few (one or two) grammar, spelling, and punctuation errors
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3 to >2.0 pts Fair
Contains several (three or four) grammar, spelling, and punctuation errors
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2 to >0 pts Poor
Contains many (≥ five) grammar, spelling, and punctuation errors that interfere with the reader’s understanding
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5 pts
Total Points: 100
4. Use the template. See exemplar for example.
episodic cannabis use weekly. Allergies shellfis Mr. Harold Feldman
episodic cannabis use weekly. Allergies shellfis