Regis College Psychiatric Mental Health Evaluation Patient Case Study Paper

The purpose of this assignment is to provide you with the opportunity to analyze and synthesize the components of a complete psychiatric assessment with clinical interventions, based on evidence-based clinical practice guidelines and theoretical knowledge. This assignment allows you to demonstrate your ability to complete a full mental health assessment of your selected client’s current, psychological, physical, and social functioning. You should be able to demonstrate critical thinking and to correlate theory and practice.

Instructions

  1. Select a client or case that you have worked within either your practice or your practicum setting. Ensure that you correctly redact the appropriate information (name, etc.).
  2. Prepare a full mental health evaluation on your client. Use the resources presented in the course to help guide your evaluation. Kaplan & Saddock’s Synopsis of Psychiatry has a robust list of the categories of information you should collect and present in your evaluation report (5.1. Parts of the Initial Psychiatric Interview). This should include the following:
    1. A full psychiatric, physical, social, family, and work history including verbal reports of the client, your observations of the client, and a summary of any diagnostic aids that you have used.
    2. The use of at least one psychiatric screening or assessment tool from the literature to assist in your assessment of the client
    3. A full physical assessment in addition to the mental status exam and psychiatric history
  3. Develop a DSM-5 diagnostic assessment
    1. Support your diagnosis through a thoughtful, evidence-based analysis of the data collected in your evaluation.
  4. Propose a practical, evidence-based plan of care.
    1. Keep in mind the role of the psychiatric-mental health nurse practitioner is to assess all aspects of the patient’s health status, including health promotion,health protection, and disease prevention. Psychiatric care is interdisciplinary. Your plan of care may include the use of other mental health professionals for the delivery of appropriate care. For example, someone who has been chronically out of work and whose unemployed status has contributed to his or her depression might require social work or educational assessment to address that aspect of the client’s poor psychological functioning.

Requirements

  1. Support your assessment, diagnosis, and treatment plan with appropriate literature citations.
  2. The paper should be no more than 10 pages in length, not including a title page and references.
  3. Use current APA formatting and citations.
  4. Acronyms should not be used.
  5. The assessment must be well written and be of professional quality. It must be clear, logically developed, and free of spelling, grammatical, and syntactical errors. Use full sentences.
  6. The psychiatric-mental health nurse practitioner employs evidence-based clinical practice guidelines to guide screening activities, identifies health promotion needs, and provides anticipatory guidance and counseling addressing environmental, lifestyle, and developmental issues.

Review a sample paper (Word) to get a better sense of expectations. (attached)

Case Study Rubric (attached)

***I had already submitted this paper to another writer and I requested and received a refund. The language did not read at all like the example and did not sound clinical in basis at all. It also did not include any information regarding medications which is necessary in this.

Patient scenario that I would like used for the paper with the diagnoses and medications I would like to use:

40 year old female.

Her reason for seeking treatment- Client would like to see a psychiatric prescriber. Client reports that she has many issues with medication adherence. Went to a psychiatrist in 2009, didn’t follow through with taking medication that he prescribed. Went to an office in Dartmouth and saw a PMHNP and didn’t follow through with filling the prescription or taking the medication. In February/March of this year, started taking consistently taking it for 3 weeks and felt really good. Stopped taking the Zoloft when she began to notice weight gain. Previously had been diagnosed with bipolar but determined later through thorough neuropsychiatric testing that she did not have true manic episodes and bipolar disorder was not an appropriate diagnosis. Client reports that her therapist believes she tries overcompensating for her depression which leaves her anxious and exhausted. Has been seeing her current psychotherapist for CBT for 12 years. Reports having outbursts of anger/irritability and will feel exhausted after.

Mental health history- Client reports being first diagnosed with depression at 19 years old. Experienced lack of motivation, lethargy, irritability, sleeping too often. Also experienced symptoms of compulsivity and would be very strict with rituals and routines. Client reports that the symptoms of compulsivity are linked to the severity of depression symptoms. Currently not experiencing compulsive symptoms. In 2009, client was diagnosed by psychiatrist with bipolar disorder, unsure of which type. Client reported she was not compliant with taking her medication but told the psychiatrist that she was taking it. Client reports the bipolar disorder diagnosis was not accurate and later confirmed she does not have bipolar disorder through a neuropsych eval.

History of being prescribed the following medications but never followed through with taking them consistenly- Luvox, Topamax, Zoloft- helpful but then caused “flare ups of irritability and weight gain”, felt like she was “even keeled and present” when taking it, gained 15 pounds, Lithium- experienced weight gain, Lamictal, Ativan.

Risk assessment- Client reports that although she is not experiencing thoughts of suicidal ideation today, she was feeling this way this past weekend. Client reports she has a safety plan in place with her therapist and that she can freely reach out to her when she needs to. Client reports she often has feelings of “if I did not have kids I wouldn’t want to do this anymore, and it’s bound to happen someday”. Client reported that she has thought through a plan in the past but did not want to elaborate since she is not experiencing suicidal ideation today. Client confirmed she feels she can be safe after leaving this appointment and will contact her therapist if thoughts of suicidal ideation appear and/or worsen.

Mental Status Exam- Appearance- well groomed, Mood- euthymic, Affect- full/within normal limits, Attire- appropriate, Eye contact- average, Behavior- cooperative, Sleep- decreased (does not have issues falling asleep, but struggles staying asleep), Appetite- within normal limits, Hallucinations- none present, delusions- none present

Trauma history- Witnessed a lot of domestic violence as a child, reports isolating often throughout this period of her life.

Family history of mental illness- Only family was her sister who died this past September of sepsis after recently becoming an alcoholic. Client reports sister regularly self-medicated with substances and her perception was that she had no mental health disorders, but the client feels that she was possibly bipolar.

Medical history- Client had gastric bypass in 2011. (should be noted in the paper that extended release medications are contraindicated in gastric bypass patients because of malabsorption…please find scholarly resources to cite for this)

Substance use history- No substance use history

Legal history- no legal history

Employment/education- Client works FT as a social worker and has her bachelors degree in psychology.

Living situation- Lives at home with boyfriend and 3 children. 16 year old, 10 year old and a 5 year old. Reports that her boyfriend is her biggest support.

Clinical formulation/diagnoses- According to neuropsych testing completed, the client has the following diagnoses:

Persistent Depressive Disorder, with intermittent major depressive episodes, with current episode F34.1

Unspecified Anxiety Disorder F41.9

Other Specified Personality Disorder: mixed personality features consistent with dependent, avoidant, and borderline F60.89

At this time, this clinician feels that these diagnoses are appropriate. In the paper, please reference why these diagnoses are appropriate with the criteria from the DSM-5.

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