Comprehensive Assessment
The nurse is a member of an interdisciplinary team and must use oral and written communication to inform others of a patient’s status. A central skill of advanced practice nursing is the ability to present a patient’s history, symptoms, diagnosis, and treatment plan to relevant parties involved in treatment.
LEARNING RESOURCES
· Carlat, D. J. (2017). The psychiatric interview (4th ed.). Wolters Kluwer.
· Section II. The Psychiatric History (Chapters 14–18)
· Section III. Interviewing for Diagnosis: The Psychiatric Review of Symptoms (Chapters 23–24)
· Lorberg, B., Davico, C., Martsenkovskyi, D., & Vitiello, B. (2019). Principles in using psychotropic medication in children and adolescents. Links to an external site. In J. M. Rey & A. Martin (Eds) , IACAPAP e-textbook of child and adolescent mental health (2019 ed., pp. 1–25). International Association for Child and Adolescent Psychiatry and Allied Professions. https://iacapap.org/_Resources/Persistent/45bdffb25befc353c9f61988e82105029504ab85/A.7-Psychopharmacology-2019.1.pdf
THE ASSIGNMENT
Assessment:
· Discuss the mental status examination results.
· What were your differential diagnoses? Provide a minimum of three possible diagnoses and why you chose them. List them from highest priority to lowest priority.
· What was your primary diagnosis and why?
· Describe how your primary diagnosis aligns with DSM-5 diagnostic criteria and supported by the patient’s symptoms.
Plan:
· Describe your treatment plan using clinical practice guidelines supported by evidence-based practice.
· Include a discussion on your chosen FDA-approved psychopharmacologic agents and include alternative treatments available and supported by valid research.
· All treatment choices must have a discussion of your rationale for the choice supported by valid research.
· What were your follow-up plan and parameters?
· What referrals would you make or recommend because of this treatment session?
· Include one social determinant of health according to the Healthy People 2030 (you will need to research) as applied to this case in the realm of psychiatry and mental health.
· As a future advanced provider, what are one health promotion activity and one patient education consideration for this patient for improving health disparities and inequities in the realm of psychiatry and mental health? Demonstrate your critical thinking.
Reflection notes: What would you do differently with this patient if you could conduct the session again? If you are able to follow up with your patient, explain whether these interventions were successful and why or why not. If you were not able to conduct a follow up, discuss what your next intervention would be.
PATIENTS INFORMATION
S:16y/o female presents with chief complaint of depression and anxiety for Psychiatry initial evaluation. Patient dealing with daily symptoms. Patient is requesting medical management to aid with symptoms.
Hx of mental health: Depression, Eating Disorder
Prescription Hx: Sertraline (Zoloft)
Symptoms: Decreased pleasure, mood, Persistent sadness, poor sleep, fatigue, appetite change, self-pity, Withdrawal from others and loneliness
lack of concentration, and fidgety. Symptoms of anxiety present eg. anxiousness, or irritability
Triggers/stressors: unclear
Mood/Affect: Depressed/Dysphoric
Suicidality: None reported
Substance Use: None reported
O: Insight and Judgement: No evidence of being outside normal limits
Thought Process: No evidence of being outside normal limits
A: Depression, mild. Generalized anxiety, mild.
P: Will prescribe medication to aid with depression and anxiety symptoms. Prescribed Bupropion 150mg PO daily. Selection based on patient’s history of binge eating without purging. F/U 1 month, or sooner if needed.