Case study 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
Case study
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/watch/training-title-151
· Review this week’s Learning Resources and consider the insights they provide.
· Review the Comprehensive Psychiatric Evaluation template, which you will use to complete this Assignment.
· 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.
BY DAY 7 OF WEEK 8
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.).
· NRNP_6635_Week8_Assignment_Rubric
NRNP_6635_Week8_Assignment_Rubric |
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Criteria |
Ratings |
Pts |
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This 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• ROS |
|
20 pts |
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This 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 pts |
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This 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 diagnosis you
selected. Include pertinent positives and pertinent negatives for the
specific patient case. |
|
25 pts |
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This criterion is linked
to a Learning OutcomeReflect on this case.
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.). |
|
10 pts |
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This criterion is linked
to a Learning OutcomeProvide at least three
evidence-based, peer-reviewed journal articles or evidenced-based guidelines
that relate to this case to support your diagnostics and differential
diagnoses. Be sure they are current (no more than 5 years old). |
|
15 pts |
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This criterion is linked
to a Learning OutcomeWritten Expression and
Formatting—Paragraph development and organization:Paragraphs make clear
points that support well-developed ideas, flow logically, and demonstrate
continuity of ideas. Sentences are carefully focused—neither long and
rambling nor short and lacking substance. A clear and comprehensive purpose statement
and introduction are provided that delineate all required criteria. |
|
5 pts |
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This criterion is linked
to a Learning OutcomeWritten Expression and
Formatting—English writing standards: Correct grammar, mechanics, and
punctuation |
|
5 pts |
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Total Points: 100 |