ASSESSING AND DIAGNOSING PATIENTS WITH ANXIETY DISORDERS, PTSD, AND OCD -

Description

“Fear,” according to the DSM-5-TR, “is the emotional response to real or perceived imminent threat, whereas anxiety is anticipation of future threat” (APA, 2022). All anxiety disorders contain some degree of fear or anxiety symptoms (often in combination with avoidant behaviors), although their causes and severity differ. Trauma-related disorders may also, but not necessarily, contain fear and anxiety symptoms, but their primary distinguishing criterion is exposure to a traumatic event. Trauma can occur at any point in life. It might not surprise you to discover that traumatic events are likely to have a greater effect on children than on adults. Early-life traumatic experiences, such as childhood sexual abuse, may influence the physiology of the developing brain. Later in life, there is a chronic hyperarousal of the stress response, making the individual vulnerable to further stress and stress-related disease. For this Assignment, you practice assessing and diagnosing patients with anxiety disorders, PTSD, and OCD. Review the DSM-5-TR criteria for the disorders within these classifications before you get started, as you will be asked to justify your differential diagnosis with DSM-5-TR criteria. Please include the video case title on your submitted cover page, AND ensure that the video you use is cited on the reference page. If I have to search for your chosen video, points will be deducted.TO PREPARE:Review this week’s Learning Resources and consider the insights they provide about assessing and diagnosing anxiety, obsessive-compulsive, and trauma- and stressor-related disorders.Download the Comprehensive Psychiatric Evaluation Template, which you will use to complete this Assignment. Also review the Comprehensive Psychiatric Evaluation Exemplar to see an example of a completed evaluation document. 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.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.).SUBMISSION INFORMATIONBefore submitting your final assignment, you can check your draft for authenticity. To check your draft, access the Turnitin Drafts Select one of the following videos to use for your Assignment this week. Then, access the document “Case History Reports” and review the additional data about the patient in the specific video number you selected. Video Case Selections for AssignmentTraining Title 9500:00:10[sil.] 00:00:15UNKNOWN On your mental health checklist here, I see you checked shame and checked embarrassment. 00:00:20UNKNOWN Yes. 00:00:25UNKNOWN And checked feelings of loss of control. Is… is that all accurate? 00:00:30UNKNOWN Very. 00:00:30UNKNOWN Are those feelings weak feelings, strong feelings, somewhere in between? 00:00:35UNKNOWN Strong. 00:00:40UNKNOWN When… when did this feeling start? 00:00:40UNKNOWN About the time I started pulling out my hair. 00:00:45UNKNOWN Uh-huh. And how long ago was that? 00:00:50UNKNOWN I have, maybe six years ago. 00:00:50UNKNOWN Uh… 00:00:50UNKNOWN Could’ve been seven, I’m not sure. 00:00:55UNKNOWN Okay. Where… where on your body did you first pull out here? 00:00:55UNKNOWN Hmm, my eyebrows. 00:00:55UNKNOWN Uh-huh. 00:01:00UNKNOWN Umm…Yeah, I just started playing with them while I was at work, proofreading reports I typed umm… with more just like rubbing them, you know, playing with them, not actually pulling the hairs out just like a nervous habit. 00:01:15UNKNOWN Uh-huh. 00:01:15UNKNOWN You know that that was all. 00:01:20UNKNOWN And… and did that change what you were doing? 00:01:25UNKNOWN Umm… Well, my coworkers noticed it before I didn’t… 00:01:30UNKNOWN Uh-huh. 00:01:30UNKNOWN You know, one day she said to me uh… goodness girl, that’s how we used to talk to each other. 00:01:35UNKNOWN Oh, okay. 00:01:35UNKNOWN She said, “Goodness girl, you’re plucking out your eyebrows.” And I… I said, “I was not.” Umm… “Maybe just some fell out while I was rubbing them. They can do that, you know, like fall out or never do… 00:01:50UNKNOWN Right. Uh-huh. 00:01:50UNKNOWN Well, at least, I think they can. Then when I checked in the mirror, my… my right eyebrow had fewer hairs on my left eyebrow. 00:02:00UNKNOWN Was that the first time you ever had pulled out any hairs? 00:02:05UNKNOWN I mean, apart from maybe when getting ready for a party, you know, the first time was by accident so… 00:02:10UNKNOWN Uh… Uh-huh. And it was only your right eye… eyebrow? 00:02:15UNKNOWN Uh… Well, at first, yeah, then uh… I… I put wax on my right eye… eyebrows so that when I reached up there it felt different. 00:02:25UNKNOWN Oh, oh. 00:02:25UNKNOWN Uh… Then umm… I started playing with my left eyebrow and pulling those hairs out umm… until all the hair was gone from both eyebrows umm… I mean, some women do that for fashion and then they… they draw them in. 00:02:45UNKNOWN Right. 00:02:45UNKNOWN Mostly older women, so that’s what I did, but then they both grew back and so I never touched him again. 00:02:55UNKNOWN Uh-huh. They never pulled out eyebrow, hairs again? 00:02:55UNKNOWN Never. Mm-mm. Then uh… I just started pulling out hair from my scalp. 00:03:05UNKNOWN Mm-hmm. 00:03:05UNKNOWN It just started the same, playing and twisting, and trolling like I was a little girl and then somewhere in that I started pulling the hairs out. 00:03:20UNKNOWN How did you feel when you realize that’s what you were doing? 00:03:25UNKNOWN Oh, shit. When I felt sorry… Pardon the language, but that’s what I felt like, here we go again. 00:03:35UNKNOWN Did anyone else notice? 00:03:40UNKNOWN Coworkers, I mean, you… you can’t get anything passed at bunch. I mean, I would deliberately play and twist and twirl with my hair in places that I knew I hadn’t pulled any hair out, you know, just in case I stopped subconsciously pulled more hair out uh… but they… they noticed the bald spots. I mean, they were little bald spots, but like I said, you… you can’t get anything passed at bunch. 00:04:05UNKNOWN So you quit pulling hairs out of your eyebrows and then you started pulling hairs out of your scalp, did you pull hairs from anywhere else? 00:04:15UNKNOWN Where else can I pull hairs from? 00:04:20UNKNOWN Arms, legs, private parts. 00:04:20UNKNOWN No. Hell, no. It was bad enough I was going to bald as it was. 00:04:25UNKNOWN I… I notice you have a scarf on today. 00:04:30UNKNOWN Yeah, I’ve got a scarf on over a wig. I mean, there’s not much hair going on underneath it. No one seeing me with a bald head. No. 00:04:40UNKNOWN That… that uh… embarrasses you and makes you feel ashamed? 00:04:45UNKNOWN Yes, sir, it does. 00:04:45UNKNOWN Uh-huh. 00:04:45UNKNOWN Do you have any other habits or rituals that concern you? 00:04:50UNKNOWN What do you mean “rituals”? 00:04:55UNKNOWN Umm… Some people have habits or rituals is like, they have to touch a refrigerator a certain number of times before they open or they have to wash their hands at a certain number of times before they feel like their hands are clean, ritual something you do is a habit that maybe other people don’t usually do. 00:05:15UNKNOWN Yeah. I mean, when I have to unplug my… my mixer or… or hair dryer, I mean, not that I’m drying much hair nowadays, but I have to unplug it then plug it back in, unplug it, plug it back in… 00:05:30UNKNOWN Uh-huh. 00:05:30UNKNOWN Just same with the light switch. You know, I have to switch it on, switch off, switch it on, switch it off. 00:05:35UNKNOWN Uh-huh. How many times? 00:05:40UNKNOWN Eleven. 00:05:40UNKNOWN Eleven times plugging and unplugging and also turning on and off switches. Uh-huh. 00:05:45UNKNOWN Yes. 00:05:45UNKNOWN They must cut in your time. 00:05:45UNKNOWN Sure, it does. 00:05:50UNKNOWN Mm-hmm. How long has that been going on? 00:05:55UNKNOWN Since I was a little girl. You know, my mom would always get mad at me for taking so long, you know. I mean, I don’t know what she thought I was doing in the bathroom and bedroom for so long all the time. I can pitch her yelling at me to come downstairs to dinner or get into the car. 00:06:15UNKNOWN Uh-huh. Any other rituals? 00:06:15UNKNOWN I think that’s enough for one person. 00:06:20UNKNOWN Yeah. What… what about thoughts that get stuck in your head, they play over and over you think about it and even though you want to quit thinking about it. 00:06:35UNKNOWN Like cats? 00:06:35UNKNOWN Uh-huh. What… what about cats? 00:06:40UNKNOWN Cats carry diseases, you know. 00:06:40UNKNOWN Uh-huh. 00:06:45UNKNOWN I mean, cats being around babies can make babies sick, same with mother is carrying baby sick. Cats… cats are like pigeons carrying diseases. I think about this all the time when I’m… when I’m on the bus, when I’m walking on the grass, when I’m… when I’m sitting on the couch in my friend’s house like, I’m always worried that I might touch something, there’s some dirty cat has like licked or… or spit on on something. You know, I can’t stop thinking about it. Like, I’m worried that I might then carry that disease to some poor woman somewhere that’s pregnant with a baby or… or that my new neighbor will bring a cat or my old neighbor will get a cat like, I hate cats. 00:07:30[sil.] 00:07:35END TRANSCRIPTTraining Title 8500:00:00BEGIN TRANSCRIPT: 00:00:00[sil.] 00:00:15CAROL Sorry, I, I can’t find it. 00:00:20OFF CAMERA It’s okay. 00:00:20CAROL No, it’s not. Where is it? I never, I never leave without it. Oh Jesus. 00:00:30OFF CAMERA What is it you’re looking for? 00:00:30CAROL My cell. I never check the b. . . um, the trunk. I have to go. 00:00:45OFF CAMERA You seem very upset not to have your phone with you. 00:00:50CAROL Of course, who wouldn’t be? We’ll have to talk some other time. 00:00:55OFF CAMERA Your husband must have his phone, he called that you were running late. 00:01:00CAROL Yeah, he has his phone, but . . . 00:01:00OFF CAMERA But what? 00:01:05CAROL The children do not call their father when they want something. 00:01:10OFF CAMERA They never call your husband? 00:01:10CAROL No, they only call me. 00:01:10OFF CAMERA Uh-huh, are you expecting your children to call? 00:01:15CAROL My children are at home with the babysitter, my neighbor. She’s a widow. I just, I don’t feel comfortable, in case they need me. And I always call, they’ll be worried if I don’t. 00:01:35OFF CAMERA How often do you call your children when you’re away from home? 00:01:40CAROL I don’t know, a few times. Just normal checking. 00:01:45OFF CAMERA Do you work? 00:01:45CAROL I’m a mother, so yes, I work. 00:01:50OFF CAMERA I’m sorry, I didn’t mean to suggest parenting isn’t work. It very much is work. Do you also have a job outside of the home? 00:02:00CAROL I used to work from home. I quit my job after my last child, Colin, he’s five now. But, this really isn’t the time for this right now. Nor ever, really. I’m just here as a courtesy, no offense. 00:02:20OFF CAMERA I understand you do not want to be here. But it would be helpful if we could talk for a few minutes. Perhaps your husband can call your children. Do you want me to go get him for you? 00:02:35CAROL I’ll be fine. We can talk for five more minutes. 00:02:40OFF CAMERA Thank you. You seem to have strong feelings that you want to call your children. But you do not have strong feelings that you want to ask your husband to call them. 00:02:50CAROL He refuse. We don’t see eye-to-eye. But I’m not here for marriage counseling. 00:03:00OFF CAMERA What is your understanding about why you’re here? 00:03:00CAROL Ask my husband, Greg. 00:03:05OFF CAMERA What current concerns do you have when you leave your children? 00:03:10CAROL There’s a laundry list on that one. Start with serial rapists and end with Newtown, and you’ve only scratched the surface. 00:03:20OFF CAMERA How often do you worry about those types on incidents? 00:03:20CAROL I’m mother of three. I have to keep in mind the world as it is. Part of my job description. Every day, people die from gun deaths. 18,000 people are raped. Over 50,000 children go missing every year. 00:03:40OFF CAMERA Those are unsettling statistics. 00:03:45CAROL Dr. Phil did a profile on a serial rapist, that was horrifying. I called my friends to watch it. I TiVo’ed it for them. 00:03:50OFF CAMERA Do you follow a lot of news programs? 00:03:55CAROL Yeah. 00:03:55OFF CAMERA What do you tend to watch? 00:03:55CAROL Most of the shows. I have CNN on background for when I’m doing laundry or cooking, or prepping lessons. 00:04:05OFF CAMERA Lessons, what lessons do you prepare? 00:04:10CAROL For the children. 00:04:10OFF CAMERA Oh, do you school your children at home? 00:04:15CAROL Yes, I homeschool my children. I don’t appreciate your connotations. The stereotype that homeschooling is for religious nuts is outdated. The reality is our school systems are broken. Our public schools can’t even afford protection for our children. 00:04:35OFF CAMERA Was that one of the reasons you decided to homeschool your children was because of school violence? 00:04:45CAROL You mean… ? 00:04:45OFF CAMERA Pardon? 00:04:45CAROL Ridge View? 00:04:50OFF CAMERA Yes, Ridge View, uh-huh. 00:04:50CAROL 12 students murdered, three teachers gunned down trying to protect students. They couldn’t protect themselves. Campus police didn’t have time to stop it. That kid’s mother and father lay dead in their house for over a week before that school massacre. Today Show profiled the ex-girlfriend. She said there was plenty of warning signs. Did the administrators listen? No. No one was capable of seeing what was coming. Yet, their signs were obvious. That child murderer drew horrifying pictures in his art classes, and you know what the teachers said? 00:05:25OFF CAMERA No. 00:05:25CAROL The teachers defended him. Said his evil artwork was a school assignment. Yes, to answer your question. Yes, I think school violence is a reason for homeschooling children. 00:05:45OFF CAMERA Do these violent events seem to stay with you, hang with you? 00:05:55CAROL I see those children’s faces. They could have been my children. Greg is heartless. Instead of helping me protect our children, he sent me to a shrink. 00:06:15OFF CAMERA Do you think that there are times where you over-worry? 00:06:25CAROL I won’t lose my children. 00:06:25OFF CAMERA Do you fear that similar violent events may happen here at these schools? 00:06:35CAROL Ridge View is only 100 miles from here, 100. That may as well be one mile. 00:06:45OFF CAMERA How long have you been homeschooling your children? 00:06:50CAROL Two months. 00:06:50OFF CAMERA So you began homeschooling them, so that was about a month after the Ridge View incident shootings? 00:07:00CAROL Yeah. When I pulled the children from school, Greg and I had a big fight, but it’s for the best. The children are learning more now than they ever learned at school. They still socialize, they still have friends. Now, my girlfriends are considering doing the same with their children. They see how well mine are doing. My girlfriends are every bit as frightened as I was. This isn’t some sort of frantic phobia on my part. I’m an educated woman about these matters. Greg, doesn’t understand what it’s like to lose family. 00:07:50OFF CAMERA Do you have stronger feelings about losing people than your husband does? 00:07:55CAROL Yes, I do. 00:08:00OFF CAMERA Have you lost people who were close to you? 00:08:05CAROL My parents, car accident, drunk driver, I was 19. 00:08:10OFF CAMERA Oh, I’m sorry to hear that. 00:08:15CAROL It happens, like that. They’re gone. I won’t lose a child. I won’t lose more people I love. 00:08:25OFF CAMERA Have these fears been increasing more recently for you? Preoccupying you, more of your time? 00:08:35CAROL Yes. I think about what happened to me, to my parents, what could happen to my children. 00:08:50OFF CAMERA What is it like to realize you cannot protect them all of the time? 00:09:00CAROL That’s what Greg says. 00:09:05OFF CAMERA Do you disagree with him? 00:09:10CAROL You protect them from what you can. You stop what you can. I couldn’t prevent that driver from sideswiping my parents, pinning them to the freeway median. I can prevent another Adam Lanza from pointing a gun at my babies. I won’t send them back to school. I won’t turn off the television, and I won’t stop informing myself. I will do what I can as a mother to protect my children. I’m sorry, I have to end this now, and call my children. I’ll call them now. 00:09:45END TRANSCRIPT Training Title 4000:00:00BEGIN TRANSCRIPT: 00:00:00[sil.] 00:00:15[She nervously plays with her scarf as she breathes anxiously] 00:00:25OFF CAMERA Hello Mrs. Weidre. Are you ok? Do you want some water or something? 00:00:30MRS. WEIDRE I’m ok. I’m fine. 00:00:35OFF CAMERA I understand you wanted to see me today. 00:00:40[She breathes anxiously] 00:00:40MRS. WEIDRE I just really needed to sit and talk. 00:00:40OFF CAMERA Well, tell me what’s wrong, what are you feeling? 00:00:50MRS. WEIDRE I’m just so… so unsure. I’m tired of being stuck in my house. I don’t like it. 00:01:00OFF CAMERA Stuck in your house? Do you have difficultly leaving your house? 00:01:05MRS. WEIDRE Yes. All the time. 00:01:05OFF CAMERA When do you go out? 00:01:10MRS. WEIDRE …maybe, once or twice. 00:01:15OFF CAMERA A day? 00:01:15[She clutches her hands to her chest] 00:01:15MRS. WEIDRE A week. Tuesdays and Saturdays. 00:01:20OFF CAMERA Why Tuesday and Saturday? 00:01:30MRS. WEIDRE Because when my husband gets home, he can go with me. 00:01:35OFF CAMERA What do you do when you go out? 00:01:40MRS. WEIDRE I take walks. 00:01:40OFF CAMERA Where do you walk? 00:01:40MRS. WEIDRE I only go to the end of the block, and then I cross the street, and turn around, and I go back around the cul-de-sac. I’ll do that three times. [Losing breathe] No more, then I have to go back inside… I also go in my backyard. That’s usually okay. 00:02:15OFF CAMERA On the walks, why do you have to go back after three times? What happens? 00:02:20MRS. WEIDRE [She nervously looks around] I just can’t go any further. 00:02:25OFF CAMERA Is this a physical problem, knees or something? 00:02:30[She plays with her scarf] 00:02:30MRS. WEIDRE No. No. Well… maybe. I just can’t breathe if I’m out any longer. 00:02:40OFF CAMERA Oh, breathing? 00:02:40MRS. WEIDRE Yeah. 00:02:40OFF CAMERA What do you feel? 00:02:45MRS. WEIDRE [Her voice quivering] I’m just so frightened. Really, really scared. You don’t realize what it took for me to get here today. I really had to. I willed it. I closed my eyes and my husband turned the radio up all the way as he drove. And then he lead me into the building. 00:03:20OFF CAMERA Is there something that triggers this, anything in particular? 00:03:30MRS. WEIDRE I don’t like people. Maybe that’s it. I mean I can tolerate them. Ethan, the little boy next door, I’ll bake things for him and say hello. Sometimes, sometimes I watch him when his parents are gone. I mean I can be around people. Maybe that’s not that’s not what I meant. 00:04:00OFF CAMERA Ok, can you walk me through what happens when you do leave the house? 00:04:05MRS. WEIDRE I get shortness of breathe, everything, the world just seems to close in on me, and everything gets feels really tight, the air in my body, my chest. I get dizzy. I don’t know what’s wrong… I could be sick. What is this? 00:04:30OFF CAMERA There can be many different causes for this. What is it that frightens you? 00:04:40MRS. WEIDRE [She’s short of breathe] Death. I’m afraid to die. 00:04:45OFF CAMERA You’re afraid you might die? 00:04:50MRS. WEIDRE Yes. Among other things but that’s what pops into my head. 00:04:55OFF CAMERA Is there other stuff? 00:05:00[sil.] 00:05:05MRS. WEIDRE Cars go to fast. And there’s murders and rapes that I see on the news. And flashfloods. I just think its close, its safer to stay close to home. 00:05:15OFF CAMERA How long have you had this fear? 00:05:20MRS. WEIDRE I don’t really know. 00:05:20OFF CAMERA Do you know when it all started? 00:05:25MRS. WEIDRE I’m not sure. 00:05:30OFF CAMERA Do you know what started it? 00:05:30MRS. WEIDRE No. 00:05:35OFF CAMERA When was the last time you really ventured out for any length of time? 00:05:40MRS. WEIDRE Fifteen years. 00:05:45[She nervously shifts in her chair] 00:05:45OFF CAMERA That long. Is this the farthest you’ve been in fifteen years? What happened fifteen years ago? 00:06:00MRS. WEIDRE I don’t really know. 00:06:05OFF CAMERA There is nothing that happened to you personally that could have made you afraid of dying? 00:06:10MRS. WEIDRE I always was. My mother died the year before that. But it happened little by little. First it was planes. And then I couldn’t drive on the freeway, then I couldn’t drive at all, then errands, then it was going out… and soon… here I am. 00:06:40OFF CAMERA It must have taken you extraordinary courage to come here today. What finally brought you to see me? 00:06:50MRS. WEIDRE My grandson was born. But I couldn’t go and see him. I still haven’t seen him. My daughter gave birth last week and she’s not going to bring him to see me for several months and I don’t want to wait that long. 00:07:10OFF CAMERA You miss out. 00:07:15MRS. WEIDRE Yes! Of course I do! My grandson is a thousand miles away and I can’t leave the God damned house. 00:07:25[sil.] Required MediaNRNP_6635_Week4_Assignment_RubricNRNP_6635_Week4_Assignment_RubricCriteriaRatingsPtsThis 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• ROS20 to >17.0 ptsExcellentThe 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 ptsGoodThe 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 ptsFairThe 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 ptsPoorThe 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 ptsThis 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 ptsExcellentThe 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 ptsGoodThe response accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are accurately documented.15 to >13.0 ptsFairDocumentation 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 ptsPoorThe response provides incomplete or inaccurate documentation of the patient’s physical exam. Systems may have been unnecessarily reviewed, or, objective documentation is missing.20 ptsThis 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 diagn

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NRNP 6635 Case History Reports
Use these case histories to supplement the information about the patients in the video case
studies.
Table of Contents
Week 3: Mood Disorders ………………………………………………………………………………………….. 3
Training Title 2 ………………………………………………………………………………………………………………….3
Training Title 8 ………………………………………………………………………………………………………………….3
Training Title 18 ………………………………………………………………………………………………………………..3
Training Title 28 ………………………………………………………………………………………………………………..4
Training Title 38 ………………………………………………………………………………………………………………..4
Training Title 43 ………………………………………………………………………………………………………………..5
Training Title 150 ………………………………………………………………………………………………………………5
Training Title 118 ………………………………………………………………………………………………………………6
Training Title 144 ………………………………………………………………………………………………………………6
Week 4: Anxiety Disorders, PTSD, and OCD………………………………………………………………….. 7
Training Title 15 ………………………………………………………………………………………………………………..7
Training Title 21 ………………………………………………………………………………………………………………..7
Training Title 37 ………………………………………………………………………………………………………………..8
Training Title 40 ………………………………………………………………………………………………………………..8
Training Title 55 ………………………………………………………………………………………………………………..9
Training Title 85 ………………………………………………………………………………………………………………..9
Training Title 95 ………………………………………………………………………………………………………………..9
Week 7 Schizophrenia and Other Psychotic Disorders; Medication-Induced Movement
Disorders ……………………………………………………………………………………………………………….10
Training Title 9 ……………………………………………………………………………………………………………….. 10
Training Title 24 ……………………………………………………………………………………………………………… 10
Training Title 29 ……………………………………………………………………………………………………………… 11
Training Title 134 ……………………………………………………………………………………………………………. 11
Week 8 Substance-Related and Addictive Disorders………………………………………………………12
Training Title 82 ……………………………………………………………………………………………………………… 12
Training Title 114 ……………………………………………………………………………………………………………. 12
Training Title 151 ……………………………………………………………………………………………………………. 13
Week 10 Neurocognitive and Neurodevelopmental Disorders ………………………………………..13
Training Title 48 ……………………………………………………………………………………………………………… 13
Training Title 50 ……………………………………………………………………………………………………………… 13
Week 3: Mood Disorders
Training Title 2
Name: Ms. Natalie Crew
Gender: female
Age:17 years old
T 97.4 P-82 R-1 20 128/84 Ht 5’2” Wt 192lbs
Background: Recently started an accelerated high school business program in Chicago, Illinois
after growing up and living in New Orleans her whole life. Grew up with both parents and four
brothers. Currently lives in on a specialty high school campus dormitory. Currently a full-time
student and works part time in the local coffee shop. Not married, currently single. She has no
previous psychiatric history; takes no medications. There is history of depression, denied
substance use history for her or family. No legal hx NKDA
Symptom Media. (Producer). (2016). Training title 2 [Video].
https://go.openathens.net/redirector/waldenu.edu?url=https://video.alexanderstreet.com/wa
tch/training-title-2
Training Title 8
Name: Mrs. Abrianna Tilman
Gender: female
Age: 27 years old
T- 98.6 P- 88 R 18 154/92 Ht 5’1 Wt 230lbs
Background: Recently had her first child two months ago. Currently married; stay at home
mother after working in community library for 5 years. Grew up with her mother after her
parents divorced when she was 16; has two sisters in Troy, Alabama. Completed education
through bachelor’s level, majoring in English Literature. No previous suicidal gestures. Brother
committed suicide via GSW. She denied drugs/alcohol; brother was addicted to
methamphetamines. Hx of HTN-prescribed Trandate 100mg twice daily, admits to missing doses
due to forgetting. No legal hx. Allergies: PCN
Symptom Media. (Producer). (2016). Training title 8 [Video].
https://go.openathens.net/redirector/waldenu.edu?url=https://video.alexanderstreet.com/wa
tch/training-title-8
Training Title 18
Name: Ms. Rosario Campbell
Gender: female
Age:25 years old
T-97.7 P-70 R-18 118/72 Ht 5’3 Wt 123lbs
Background: Currently living off-base in El Paso, Texas, active duty in the Army, MOS 92M
Mortuary Affairs Specialist. Grew up in McAllen TX with both parents and one brother.
Completed education through high school. Currently partnered. No children. Mother history of
depression; brother hx of cannabis use. No medical history. No legal hx; allergy: cipro previous
medication trials: sertraline, fluoxetine both with good effects when taking.
Symptom Media. (Producer). (2017). Training title 18 [Video].
https://go.openathens.net/redirector/waldenu.edu?url=https://video.alexanderstreet.com/wa
tch/training-title-18
Training Title 28
Name: Mrs. Ada Carson
Gender: female
Age: 54 years old
T- 97.6 P- 94 R 22 162/84 Ht 5’5 Wt 144lbs
Background: Currently living in Sioux Falls, South Dakota, working full-time as a contract
negotiator in a financial company. Has an MBA. Lives with her husband and two teenage twin
sons. Born and raised in Trenton, NJ, with her father and two brothers, her mother deceased
when she in MVA when she was 12 years old. Brother has depression; mother has history of
being a “functioning alcoholic”. Recently informed by her PCP she has a “fatty liver.” Allergies:
codeine
Symptom Media. (Producer). (2016). Training title 28 [Video].
https://go.openathens.net/redirector/waldenu.edu?url=https://video.alexanderstreet.com/wa
tch/training-title-28
Training Title 38
Name: Mr. Elijah Loman
Gender: male
Age:18 years old
T- 98.3 P- 93 R 22 118/68 Ht 5’7 Wt 149lbs
Background: Currently lives with his sister and two parents in Durham, NC. Not currently
employed. Completed high school, not currently in school. Hx of treatment for mood disorder
began age 15, previous trials of risperidone, quetiapine off and on, side effects of wt. gain. Has
hx of a six-day hospitalization one year ago after found wandering at night in the mall parking
lot without clothes. He refused medication due to previous experiences. Not currently partnered.
He has been sexually inappropriate with comments to female neighbors; pulled his pants down in
the mall. Denies any recent alcohol or substance use. Father has history of bipolar disorder. No
history of self-harm behaviors, no family suicides. Mother reports he has slept 4-5 hours in past
week, up spending money buying and playing new video games and says he is writing a book on
how others can be a video game master. Appetite is decreased. No medical hx; Hx of vandalism
as a juvenile. Has pending court date for indecent exposure. Allergies: latex
Symptom Media. (Producer). (2016). Training title 38 [Video].
https://go.openathens.net/redirector/waldenu.edu?url=https://video.alexanderstreet.com/wa
tch/training-title-38
Training Title 43
Name: Mr. Elijah Loman
Gender: male
Age:20 years old
T- 97.2 P- 84 R 18 118/68 Ht 5’7 Wt 156lbs
Background: Currently lives with his sister and her husband who are his legal guardians as
parents deceased when he was 15 and he was deemed to need a fiduciary and guardian by the
court system. Not currently employed. Completed high school, not currently in school. Hx of
treatment for mood disorder began age 15, previous trials of Depakote, Quetiapine off and on,
side effects of akathisia. Has hx of a multiple hospitalization, last was 4 months ago when he
exposed his genitals to girls at the mall. . Not currently partnered. He is currently in hospital
admitted one week ago, was initiated on lithium 300mg po three times daily and risperidone 1mg
at bedtime. Denies any recent alcohol or substance use. Paternal uncle has history of bipolar
disorder. No history of self-harm behaviors, no family suicides. Appetite is decreased. No
medical hx; hospital admission labs within normal ranges, UDS negative; Hx of truancy as a
juvenile. Has pending court date for indecent exposure. Allergies NKDA
Symptom Media. (Producer). (2016). Training title 43 [Video].
https://go.openathens.net/redirector/waldenu.edu?url=https://video.alexanderstreet.com/wa
tch/training-title-43
Training Title 150
Name: Ms. Cheyenne Lisenbe
Gender: female
Age:18 years old
T- 97.4 P- 94 R 22 136/86 Ht 5’2 Wt 121
Background: Currently living with her parents in Locust Grove, Oklahoma along with two
younger sisters and 1 older brother. She is a senior in high school, not currently partnered,
reports she is bisexual, lately hyper-sexual reporting increase of unprotected sex. She has been
stealing money out of her grandmother’s purse to buy clothes, shoes, purses, “and just other
things. She has history of treatment since age 9 for conduct disorder, depression, history of
taking citalopram which worsened her irritability, aggression, impulsivity. She has been in a 90day teen residential mental health facility discharged three months ago with lithium 300mg in am
and 600mg at bedtime, aripiprazole 2.5mg in the morning. When discharged, her labs were
within normal ranges and urine toxicology negative. She was positive for cannabis upon
admission. Her parents believe she is hiding her medication as she has made comments “they
slow me down; they make me not think fast” She has hx of domestic violence toward her older
brother with juvenile assault charge. No current legal issues. Her grandmother has hx of bipolar
disorder; her mother and her maternal aunt have anxiety. She is sleeping 2-3hrs/24 hrs. Reports
her appetite “ravishing.” She has no medical issues; has Nexplanon implant; hx of self-harm with
cutting, last engaged in the behavior 6 months ago.
Symptom Media. (Producer). (2018). Training title 150 [Video].
https://go.openathens.net/redirector/waldenu.edu?url=https://video.alexanderstreet.com/wa
tch/training-title-150
Training Title 118
Name: Mr. Connor Walsh
Gender: male
Age: 57 years old
T- 97.2 P- 94 R 20 156/88 Ht 5’8 Wt 163lbs
Background: Born and raised in Peru Indiana Is staying at a shelter after being homeless in
MacArthur Park for 1 year in Los Angeles. He lost his apartment and his job working part-time
at Home Depot. Enjoys playing music. He has long hx of mental health treatment since age 19.
Previous medication trials include lithium (was effective), Depakote (gastric upset), aripiprazole
(akathisia), risperidone (hyperprolactinemia), haloperidol (dystonia), quetiapine (didn’t give a
fair trial), Poor historian. divorced once, reports being gay, no children; estranged from only
living sister, parents deceased. He is not sure of his family mental health or substance use history
but feels like he is most like his aunt, she has history of mental health treatment “but
I’m not sure for what.” States that he got a master’s degree in music theory at Stanford. Admits
to 3-6 drinks of alcohol when “playing music in the clubs”, denied illicit drugs, has history of
intentional drug overdose at age 22, history of 8 inpatient psychiatric hospitalization, most recent
was 8 months ago. hx of one detox admission 15 years ago Allergies: bee stings
Symptom Media. (Producer). (2018). Training title 118 [Video].
https://go.openathens.net/redirector/waldenu.edu?url=https://video.alexanderstreet.com/wa
tch/training-title-118
Training Title 144
Name: Ms. Amy Hartford
Gender: female
Age: 26 years old
T- 98.2 P- 70 R 18 128/76 Ht 5’0 Wt 152lbs
Background: Currently lives in Scottsdale, AZ, divorced with two children a daughter age 8 and
son age 4. Born and raised in Mesa, AZ with her mother and two sisters Works as paralegal, has
an associate degree; no legal hx; allergic to dicyclomine; history of rosacea
Symptom Media. (Producer). (2018). Training title 144 [Video].
https://go.openathens.net/redirector/waldenu.edu?url=https://video.alexanderstreet.com/wa
tch/training-title-144
Week 4: Anxiety Disorders, PTSD, and OCD
Training Title 15
Name: Mr. Ralph Newsome
Gender: male
Age:19 years old
T- 97.0 P- 70 R 18 116/68 Ht 5’9 Wt 175lbs
Background: Lives in Columbus, OH with his dog Chance, only child. Parents live locally.
Works part time in Construction. Not currently partnered. No previous psychiatric history.
Symptoms began in the last 2 months when he discovered he is being activated with the Navy
Reserves. His MOS is CM3 Construction Mechanic; no medical illnesses, no legal hx. Allergies:
NKDA; sleeps 8hrs; appetite good
Symptom Media. (Producer). (2017). Training title 15 [Video].
https://go.openathens.net/redirector/waldenu.edu?url=https://video.alexanderstreet.com/wa
tch/training-title-15
Training Title 21
Name: Sergeant Berry Sullivan
Gender: male
Age:27 years old
T- 98.8 P- 86 R 18 B/P 122/7 Ht 5’8 Wt 160lbs
Background: He entered the military just after high school and did three long tours of duty in
warzones. He separated from active duty in the Marines (MOS 0800 Field Artillery) six months
ago after eight years of service. He is engaged to be married in 8 months and is using his GI
Education Bill to attend online college for accounting. He said he grew up poor and would not do
much else if he didn’t go into the military. He denies ever using any drugs and avoids alcohol
because his father was “abusive when he was drunk.” Father is still alive, unwell (DM, cirrhosis,
HTN), still drinking. Paternal grandfather was also a veteran and suffered depression at times
though he never told anyone except the patient because of their combat connection. He has one
younger brother and one older sister. He lives in a different state, approximately five hours from
his parents and siblings. After the military, he and his fiancé moved because she got a much
better opportunity. They want kids someday. Has service-connected asthma, seasonal allergies;
no hx of psychiatric or substance use treatment.
Symptom Media. (Producer). (2016). Training title 21 [Video].
https://go.openathens.net/redirector/waldenu.edu?url=https://video.alexanderstreet.com/wa
tch/training-title-21
Training Title 37
Name: Mr. Luca Esposito
Gender: male
Age:21 years old
T- 97.4 P- 112 R 22 122/68 Ht 6’1Wt 198lbs
Background: Lives alone in Orlando, FL raised by parents in Buffalo, NY, only child. He is a
full- time student obtaining a degree for graphic design. works part-time as Uber driver. Has a
girlfriend from high school. No previous psychiatric history. No medical illnesses; no history of
psychiatric treatment; denied drugs or alcohol; Allergies: NKDA; sleeps 6 hrs.; appetite eats 3
meals/day, likes to keep a routine schedule.
Symptom Media. (Producer). (2016). Training title 37 [Video].
https://go.openathens.net/redirector/waldenu.edu?url=https://video.alexanderstreet.com/wa
tch/training-title-37
Training Title 40
Name: Ms. Connie Weidre
Gender: female
Age: 53 years old
T- 99.0 P- 102 R 24 156/86 Ht 5’4 Wt 1lbs73
Background: Lives with her husband in Memphis, TN, has one daughter age 25. She has never
worked. Raised by mother, she never knew her father. Mother with hx of generalized anxiety and
was verbally abusive, abused benzodiazepines; no substance hx for patient. No previous
psychiatric treatment. Has one glass red wine with dinner. Sleeps 12-13 hrs.; appetite decreased.
Has overactive bladder, untreated. Allergic to Zofran; complains of headaches, takes prn
Tylenol, has diarrhea 2-3 times weekly, takes OTC Imodium.
Symptom Media. (Producer). (2016). Training title 40 [Video].
https://go.openathens.net/redirector/waldenu.edu?url=https://video.alexanderstreet.com/wa
tch/training-title-40
Training Title 55
Name: Matilda Johnson
Gender: female
Age: 8 years old
T-98.0 P 70 R 24 B/P 110/68
Ht 45 inches Wt 57lbs
Vaccinations are up to date, on target with developmental milestones. Appetite, she is a picky
eater per mom. NKDA
Symptom Media. (Producer). (2017). Training title 55 [Video].
https://go.openathens.net/redirector/waldenu.edu?url=https://video.alexanderstreet.com/wa
tch/training-title-55
Training Title 85
Name: Mrs. Isla Flanagan
Gender: female
Age: 47 years old
T- 98.0 P- 82 R 18 136/62 Ht 5’0 Wt 123lbs
Background: Born and raised in Northern Ireland, parents brought her and her one sister to U.S.
when she was 15 to go to U.S. university where she met her husband. They live in Charleston,
SC. She obtained her master’s degree in education; no history of mental health or substance use
treatment, no family history. Her husband reported a recent school shooting nearby 3 weeks ago
“flipped a switch” in her. She is watching the news 24/7, barely sleeping, and even when she
does, it is only a few hours, Appetite is decreased. Hx of hysterectomy, NKDA, no legal hx.
Symptom Media. (Producer). (2017). Training title 85 [Video].
https://go.openathens.net/redirector/waldenu.edu?url=https://video.alexanderstreet.com/wa
tch/training-title-85
Training Title 95
Name: Ms. Serenity Jackson
Gender: female
Age: 24years old
T- 97.5 P- 80 R 18 118/74 Ht 5’2 Wt 136lbs
Background: Born and raised in Gainesville, FL with her mother and 4 older brothers; her
mother has hx of panic disorder, 2 brothers hx of cannabis; father abandoned the family when
she was 3 years old. One brother is in prison for burglary. no previous mental health treatment,
no medications; NKDA; no legal hx; sleeping 9 hrs.; Appetite is good. She has an associate of
arts degree and works for Leaders furniture warehouse. She has DX of diabetes since age 8. She
recalls having great difficulty with her medical condition (uncontrolled blood sugar, fighting
with mother over needle sticks, “kids want candy, and I was so different because of my diet”).
She recalls having a difficult relationship with her mother who was a nurse and really worked
hard to control her daughter’s diabetes. She is not in a relationship, identifies as lesbian but has
not come out to the family. Only her closest co-workers know She stated, “I don’t see why I
would, they wouldn’t understand, and this is not important right now.”
Symptom Media. (Producer). (2018). Training title 95 [Video].
https://go.openathens.net/redirector/waldenu.edu?url=https://video.alexanderstreet.com/wa
tch/training-title-95
Week 7 Schizophrenia and Other Psychotic Disorders; MedicationInduced Movement Disorders
Training Title 9
Name: Ms. Fatima Branning
Gender: female
Age: 28 years old
T- 98.4 P- 82 R 18 124/74 Ht 5’0 Wt 118lbs
Background: Raised by parents, lives alone in Coronado, CA. Only child. Works as an
administrative assistance in car sales, has a bachelor’s in hospitality. Has medical history of
scoliosis, currently treated with chiropractic care. Guarded and declined to discuss past
psychiatric history. Denied family mental health issues, declined to allow you to speak to parents
for collaborative information. Allergies: latex; menses regular, no birth control
Symptom Media. (Producer). (2016). Training title 9 [Video].
https://go.openathens.net/redirector/waldenu.edu?url=https://video.alexanderstreet.com/wa
tch/training-title-9
Training Title 24
Name: Ms. Jess Davies
Gender: female
Age: 30 years old
T- 98.6 P- 86 R 20 120/70 Ht 5’2 Wt 126lbs
Background: Jess is brought for evaluation by her 2 roommates who are concerned with
behaviors. She had some issues with depression after aunt died but worsened in the 12 days after
she witnessed her brother killed via GSW in a gas station burglary. She is estranged from her
parents and her brother was her only sibling. She is only sleeping 2 hours/24hrs; she will only eat
canned foods. She smokes cannabis daily since she was 17 and goes out on weekdays couple
times with her roommates and has couple drinks of beer. She was prescribed alprazolam 1mg
twice daily as needed by her PCP for 15 days. She works in a bakery. Allergies: medical tape
Symptom Media. (Producer). (2016). Training title 24 [Video].
https://go.openathens.net/redirector/waldenu.edu?url=https://video.alexanderstreet.com/wa
tch/training-title-24
Training Title 29
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
Symptom Media. (Producer). (2016). Training title 29 [Video].
https://go.openathens.net/redirector/waldenu.edu?url=https://video.alexanderstreet.com/wa
tch/training-title-29
Training Title 134
Name: Mrs. Patricia Warren
Gender: female
Age: 42 years old
Background: Patricia was brought in under a emergency evaluation order after her best friend,
Felicia, after the police for Patricia locking herself in a closet and screaming loudly for over an
hour. EMS was able to calm her with a small dose of Ativan enroute to the emergency
department. This is Patricia’s third presentation to the emergency room in 2 weeks. She had one
psychiatric hospitalization around this same last year. No self-harm behaviors but has assaulted
other in the past. No hx of TBI. Sleeps 1–2-hour increments for total of 6 hrs. daily, refuses to
sleep at night. Refused vitals, wt., refuses labs, not cooperative. She obtains SSDI. She lives in
Cameron, Montana. She denies ever using any drugs and drinks one glass wine weekly. She has
a sister who is five years older, both parents deceased in the last three years. She has no children,
her husband is out of town, truck driver. Family history includes that her father had two previous
inpatient psychiatric hospitalizations for paranoia Mother had history of bipolar depression.
Paternal grandmother had “shock therapy”. Denies history of trauma experience, but her friend
reports parents death was extremely difficulty for Patricia. no current legal charges. dropped out
of high school in 11th grade, was pregnant and had abortion. allergies: Clozaril
Symptom Media. (Producer). (2018). Training title 134 [Video].
https://go.openathens.net/redirector/waldenu.edu?url=https://video.alexanderstreet.com/wa
tch/training-title-134
Week 8 Substance-Related and Addictive Disorders
Training Title 82
Name: Lisa Tremblay
Gender: female
Age: 33 years old
T- 100.0 P- 108 R 20 180/110 Ht 5’6 Wt 146lbs
Background: Lisa is in a Naples, FL detox facility thinking about long term rehab. She is
considering treatment for her Hep C+ but needs to get clean first. She has been abusing opiates,
approximately $100 daily. She admits to cannabis 1–2 times weekly (“I have a medical card”),
and 1/2 gallon of vodka daily. She has past drug paraphernalia possession arrest. Her admission
labs. abnormal for ALT 168 AST 200 ALK 250; bilirubin 2.5, albumin 3.0; her GGT is 59; UDS
positive for opiates, THC. Positive for alcohol or other drugs. BAL .308; other labs within
normal ranges. She reports sexual abuse as child ages 6-9 perpetrator being her father who went
to prison for the abuse and drug charges. She is estranged from him. Mother lives in Maine, hx
of agoraphobia and benzodiazepine abuse. Older brother has not contact with family in last 10
years, hx of opioid use. Sleeps 5-6 hrs., appetite decreased, prefers to get high instead of eating.
Allergies: azithromycin
Symptom Media. (Producer). (2017). Training title 82 [Video].
https://go.openathens.net/redirector/waldenu.edu?url=https://video.alexanderstreet.com/wa
tch/training-title-82
Training Title 114
Name: Ally Chen
Gender: female
Age: 44 years old
Background: Only child, raised by parents in Philadelphia, PA. Has PhD in biology and master’s
degree in high school education (8–12). Her supervisor has asked the school EAP counselor to
intervene with concerns regarding potential substance use in effort to facilitate getting her help
and be able to retain her. She is divorced, has a 4-year-old son who lives with his father. Appetite
healthy, sleeping 9 hours/24 hrs., wakes 2-3 times during the night. Denied drug use. had DUI
when she was age 21.
Symptom Media. (Producer). (2018). Training title 114-2 [Video]. https://video-alexanderstreetcom.ezp.waldenulibrary.org/watch/training-title-114-2
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/wa
tch/training-title-151
Week 10 Neurocognitive and Neurodevelopmental Disorders
Training Title 48
Name: Sarah Higgins
Gender: female
Age: 11 years old
T- 97.4 P- 58 R 14 98/62 Ht 4’5 Wt 65lbs
Background: no history of treatment, developmental milestones met on time, vaccinations up to
date. Sleeps 9-10hrs/night, meals are difficult as she has hard time sitting for meals, she does get
proper nutrition per PCP. she has a younger brother. lives with her parents in Washington,
D.C. No hx of head trauma.
Symptom Media. (Producer). (2017). Training title 48 [Video].
https://go.openathens.net/redirector/waldenu.edu?url=https://video.alexanderstreet.com/wa
tch/training-title-48
Training Title 50
Name: Harold Brown
Gender: male
Age:60 years old
T- 98.8 P- 74 R 18 134/70 Ht 5’10 Wt 170lbs
Background:
Has bachelor’s degree in engineering. He dates casually, never married, no children. Has one
younger brother. Sleeps 7 hours, appetite good. Denied legal issues; MOCA 28/30 difficulty with
attention and delayed recall; ASRS-5 21/24; denied hx of drug use; enjoys one scotch drink on
the weekends with a cigar. Allergies Dilaudid; history HTN blood pressure controlled with
Cozaar 100mg daily, angina prescribed ASA 81mg po daily, valsartan 80mg daily.
Hypertriglyceridemia prescribed fenofibrate 160mg daily, has BPH prescribed tamsulosin 0.4mg
po bedtime.
Symptom Media. (Producer). (2017). Training title 50 [Video].
https://go.openathens.net/redirector/waldenu.edu?url=https://video.alexanderstreet.com/wa
tch/training-title-50
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
ill

Related Questions: