Psychiatric Evaluation

Patient – KF is a 7 year White male. He was sodomized by his 13 year half brother (father’s son). KF was 4 years when this occurred and has been in counseling for 3 years. He has a total of 6 older brothers by his father. The incident caused a strain in his parents’ relationship due to his mother’s anger regarding the molestation perpetrated on KF. The offender (older brother) only received probation and therapy as punishment. The parents separated as a result of this incident. The mother felt guilty because she was in the house when the incident occurred. Today, the parents have gotten back together and recently married and had 2 additional children. KF is having disciplinary and sexual issues at school. He struggles with listening and following directions. He was accused of lifting up a little girl’s dress. He has been diagnosed with ADHD and is being treated for it. KF sneaks food at night after everyone is sleeping and hides the evidence in his room. He prefers snacks over what his mother cooks for dinner. He has also started urinating in empty bottles.
Psychiatric notes are a way to reflect on your practicum experiences and connect the experiences to the learning you gain from your weekly Learning Resources. Comprehensive psychiatric evaluation notes, such as the ones required in this practicum course, are often used in clinical settings to document patient care.
For this Assignment, you will document information about a patient that you examined at your practicum site, using the Comprehensive Psychiatric Evaluation Note Template provided. You will then use this note to develop and record a case presentation for this patient.
TO PREPARE
• Review this week’s Learning Resources and consider the insights they provide about impulse-control and conduct disorders.
• Select a patient for whom you conducted psychotherapy for an impulse control or conduct disorder during the last 6 weeks. Create a Comprehensive Psychiatric Evaluation Note on this patient using the template provided in the Learning Resources. There is also a completed template provided as an exemplar and guide. All psychiatric evaluation notes must be signed by your Preceptor. When you submit your note, you should include the complete comprehensive evaluation note as a Word document and pdf/images of the completed assignment signed by your Preceptor. You must submit your note using Turnitin.
Please Note: Electronic signatures are not accepted. If both files are not received by the due date, Faculty will deduct points per the Walden Grading Policy.
• Then, based on your evaluation of this patient, develop a video presentation of the case. Plan your presentation using the Assignment rubric and rehearse what you plan to say. Be sure to review the Kaltura Media Uploader resource in the left-hand navigation of the classroom for help creating your self-recorded Kaltura video.
• Include at least five scholarly resources to support your assessment and diagnostic reasoning.
• Ensure that you have the appropriate lighting and equipment to record the presentation.
THE ASSIGNMENT
• Include subjective and objective data; assessment from most recent mental status exam; current psychiatric diagnosis including differentials that were ruled out; current psychotherapeutic plan (include one health promotion activity and one patient education strategy you provided); and patient progress toward treatment goals.
o Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What was the duration and severity of their symptoms? How are their symptoms impacting their functioning in life?
o Objective: What observations did you make during the psychiatric assessment?
o Assessment: Discuss the patient’s mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses in order of highest to lowest priority and explain why you chose them. What was your primary diagnosis and why? Describe how your primary diagnosis aligns with DSM-5-TR diagnostic criteria and is supported by the patient’s symptoms.
o Plan: Describe your treatment modality and your plan for psychotherapy. Explain the principles of psychotherapy that underline your chosen treatment plan to support your rationale for the chosen psychotherapy framework. What were your follow-up plan and parameters? What referrals would you make or recommend as a result of this psychotherapy session?
o Reflection notes: What would you do differently in a similar patient evaluation? Reflect on 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.