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Comprehensive Psychiatric Evaluation

• 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.

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.).

Case Video
• Symptom Media. (Producer). (2018). Training title 151 [Video]. https://go.openathens.net/redirector/waldenu.edu?url=https://video.alexanderstreet.com/watch/training-title-151

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.

Full Answer Section

Duration of symptoms: The patient reported that the chest pain had been going on for about 2 hours. The shortness of breath, nausea, and lightheadedness had been going on for about 1 hour.
Severity of symptoms: The patient rated the severity of the chest pain as 8 out of 10. The shortness of breath, nausea, and lightheadedness were rated as 6 out of 10.
Impact of symptoms on functioning: The patient reported that the chest pain was making it difficult to breathe and walk. The shortness of breath, nausea, and lightheadedness were making it difficult to concentrate and think clearly.

The patient's symptoms are consistent with a number of different conditions, including:

Myocardial infarction: This is a heart attack that occurs when blood flow to the heart is blocked.
Anxiety attack: This is a sudden and intense episode of anxiety that can cause a variety of physical symptoms, including chest pain, shortness of breath, and nausea.
Pleurisy: This is an inflammation of the lining of the lungs that can cause chest pain, shortness of breath, and coughing.
Gastritis: This is an inflammation of the lining of the stomach that can cause chest pain, nausea, and vomiting.

The differential diagnosis will be based on the patient's medical history, physical examination, and laboratory tests. The patient's medical history includes a history of high blood pressure and high cholesterol. The physical examination revealed no abnormalities. The laboratory tests are pending. The patient's symptoms are impacting their functioning in life by making it difficult to breathe, walk, concentrate, and think clearly. The patient is also experiencing anxiety and fear. The next step in the evaluation is to review the patient's laboratory tests and discuss the differential diagnosis with the patient. The patient will then be started on a treatment plan, which may include medication, lifestyle changes, or further testing.

Sample Answer

Chief complaint: The patient presented with a chief complaint of chest pain.
Symptomology: The patient described the chest pain as sharp and stabbing. The pain was located in the center of the chest and radiated to the left arm. The pain was worse with exertion and relieved with rest. The patient also reported shortness of breath, nausea, and lightheadedness.