Pertinent Positives And Pertinent Negatives For The Specific Patient Case Essay

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. Pertinent Positives And Pertinent Negatives For The Specific Patient Case Essay

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!
  

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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 critical-thinking 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 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.)  Pertinent Positives And Pertinent Negatives For The Specific Patient Case Essay

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. 

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. Pertinent Positives And Pertinent Negatives For The Specific Patient Case Essay

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. Pertinent Positives And Pertinent Negatives For The Specific Patient Case Essay

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?

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. Pertinent Positives And Pertinent Negatives For The Specific Patient Case Essay

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.

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.  Pertinent Positives And Pertinent Negatives For The Specific Patient Case Essay

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 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.). Pertinent Positives And Pertinent Negatives For The Specific Patient Case Essay

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.

NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template

Subjective

CC (chief complaint): He is not sleeping, spending money excessively, and has been acting bizarrely,” as reported by his mother.

HPI: Mr. Elijah Loman is an 18-year-old male who has been referred to the psychiatry department because of recent behavioral concerns. His mother says he has been getting only 4-5 hours of sleep a night for the past week and has been awake at night playing and buying video games. He says that he is working on a guide on how to be a video game master. He has a reduced appetite. He has a history of mood disorder treatment starting at 15 years with trials of risperidone and quetiapine that were discontinued due to weight gain. He was admitted for six days one year ago after he was discovered wandering naked in a mall parking lot at night. He has sexually harassed women and once exposed himself in a mall to some ladies. The patient has no history of alcohol or substance use within the last 1 year. His behavior has caused significant distress and concern, especially given his history and the pending legal issues for indecent exposure.  Pertinent Positives And Pertinent Negatives For The Specific Patient Case Essay

Past Psychiatric History:

• General Statement: First treated at “age 15 for mood disorder.”
• Caregivers (if applicable): Lives with his parents and sister.
• Hospitalizations: Six days of hospitalization one time in a year, which was after being picked from a mall parking lot naked.
• Medication trials: Risperidone (discontinued due to weight gain), Quetiapine (discontinued due to weight gain).
• Psychotherapy or Previous Psychiatric Diagnosis: Previous “mood disorder diagnosis,” specifics of psychotherapy not detailed.

Substance Current Use and History: Stating that he does not consume alcohol or substances at present or in the past.

Family Psychiatric/Substance Use History: Father has a history of bipolar disorder. “No family history of suicides.”

Psychosocial History: Mr. Loman resides in his parent’s home and has a sister in Durham, North Carolina. He did high school though he is not working at the moment nor is learning in any institution. He does not have a boyfriend or girlfriend at the moment. Previous criminal record for vandalism, which has a juvenile court hearing for indecent exposure pending. He has no significant medical history and no history of self-harm.

Medical History: No medical illnesses and surgeries were reported by the participants in this study. Negative for past history of seizures or head injuries.

• Current Medications: Not currently on any medications.
• Allergies: Latex – causes an unspecified reaction.

• Reproductive Hx: Not currently sexually active; no sexual concerns reported. Pertinent Positives And Pertinent Negatives For The Specific Patient Case Essay

ROS:

• GENERAL: Reports decreased appetite. No weight loss, fever, chills, or weakness.
• HEENT: No visual loss, blurred vision, or double vision. No hearing loss, sneezing, congestion, runny nose, or sore throat.
• SKIN: No rash or itching. No changes in skin texture or color.
• CARDIOVASCULAR: No chest pain, chest pressure, or palpitations. No edema.
• RESPIRATORY: No shortness of breath, cough, or wheezing.
• GASTROINTESTINAL: No nausea, vomiting, diarrhea, or abdominal pain. Appetite is decreased.
• GENITOURINARY: No dysuria, urgency, frequency, or hematuria.
• NEUROLOGICAL: No headaches, dizziness, syncope, or seizures. No numbness or tingling.
• MUSCULOSKELETAL: No muscle pain, joint pain, or stiffness.
• HEMATOLOGIC: No history of anemia, bleeding, or bruising.
• LYMPHATICS: No history of swollen lymph nodes. No splenectomy.
• ENDOCRINOLOGIC: No reports of excessive sweating, heat or cold intolerance, or changes in thirst or urination.

Objective:

Physical exam: Not performed.

Diagnostic results: No labs results.

Assessment:

Mental Status Examination: Mr. Loman appears his stated age and is cooperative but exhibits bizarre behaviors. He is well shaven, well dressed, and is well groomed and clean. His speech is rapid, digressive and pressured. He is not well organized in his thinking with ideas that are not well connected. He had paranoid thinking about Russian infrared rays and seems to have delusional perception about certain questions and answers that he needs to write down. He seems to be in a good mood, and his emotional state is quite volatile. He does not report any auditory or visual hallucinations but is grandiose and paranoid. He negates the presence of suicidal or homicidal ideation in the present time. He is mentally present and knows where he is, but his concentration and memory seem to be compromised. Insight and judgment are low. Pertinent Positives And Pertinent Negatives For The Specific Patient Case Essay

Differential Diagnoses:

1. Bipolar I Disorder, Current Episode Manic with Psychotic Features:

• Supporting Evidence: Mr. Loman’s euphoric mood, decreased need for sleep, grandiosity, hyperactivity, pressured speech, and impaired judgment are consistent with a manic episode (Chakrabarti & Singh, 2022). His disorganized thoughts and paranoia indicate psychotic features.
• Ruling In: Symptoms align with DSM-5-TR criteria for a manic episode in Bipolar I Disorder, which includes a period of abnormally elevated mood and increased activity/energy lasting at least one week.
• Ruling Out: No evidence of substance abuse or other medical conditions that could explain the symptoms.

2. Schizoaffective Disorder, Bipolar Type:

• Supporting Evidence: Presence of psychotic symptoms (paranoia, delusions) concurrent with mood symptoms (euphoria, hyperactivity) as supported by Rossom et al. (2020).
• Ruling In: DSM-5-TR criteria for Schizoaffective Disorder require a major mood episode (manic or depressive) concurrent with psychotic symptoms.
• Ruling Out: Mr. Loman’s mood symptoms are more pronounced and continuous with the psychotic symptoms, making Bipolar I Disorder with psychotic features more fitting.

3. Substance/Medication-Induced Psychotic Disorder:

• Supporting Evidence: Paranoia and bizarre behaviors could suggest intoxication or withdrawal effects (Popa et al., 2021).
• Ruling In: DSM-5-TR criteria for Substance/Medication-Induced Psychotic Disorder include psychotic symptoms developing during or soon after substance use.
• Ruling Out: Mr. Loman denies any substance use, and there is no evidence of medication causing these symptoms. Pertinent Positives And Pertinent Negatives For The Specific Patient Case Essay

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Reflections:

I agree with the primary diagnosis of Bipolar I Disorder, Current Episode Manic with Psychotic Features. The clinical presentation strongly supports this diagnosis due to the classic symptoms of mania and concurrent psychotic features. In reflecting on this case, I learned the importance of distinguishing between primary psychotic disorders and mood disorders with psychotic features. If faced with a similar case in the future, I would ensure a thorough medical workup to rule out any organic causes for the symptoms. Additionally, I would involve the family more to gather comprehensive information and to support Mr. Loman through his treatment.

Legal/Ethical Considerations:
This case involves potential legal issues (pending court date for indecent exposure). Ethical considerations include ensuring Mr. Loman’s safety and the safety of others, given his inappropriate behaviors. Treatment decisions must respect his autonomy while balancing the need for potentially involuntary treatment due to impaired judgment and insight.

Social Determinants of Health:
Factors such as his current living situation, lack of employment or educational engagement, and legal issues are crucial. Health promotion should focus on stabilizing his mood and integrating him into a supportive routine, possibly involving vocational training or educational programs.

Health Promotion and Disease Prevention:
Given his age and the early onset of symptoms, education on medication adherence and recognizing early signs of mood changes are essential. Considering his family history of bipolar disorder, genetic counseling may be beneficial for the family. Social support and psychoeducation for both Mr. Loman and his family are critical in managing his condition. Pertinent Positives And Pertinent Negatives For The Specific Patient Case Essay