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Name: PRAC_6635_Week7_Assignment2_Rubric
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Excellent
Good

Fair
Poor
Photo ID display and professional attire
Points:
5 (5.00%)
Points Range:
5 (5.00%) - 5 (5.00%)
Photo ID is displayed. The student is dressed professionally.
Feedback:

Points:
Points Range:
0 (0.00%) - 0 (0.00%)
Feedback:

Points:
Points Range:
0 (0.00%) - 0 (0.00%)
Photo ID is not displayed. Student must remedy this before
grade is posted. The student is not dressed professionally.
Feedback:
Time

Points:
Points Range:
5 (5.00%) - 5 (5.00%)
The video does not exceed the 8-minute time limit.
Feedback:

Points:
Points Range:
0 (0.00%) - 0 (0.00%)
Feedback:
Points:

0 (0.00%)
Points Range:
0 (0.00%) - 0 (0.00%)
Feedback:
Points:

Points Range:
0 (0.00%) - 0 (0.00%)
The video exceeds the 8-minute time limit. (Note: Information
presented after the 8 minutes will not be evaluated for grade
inclusion.)
Feedback:
Description of chief complaint and history of present illness
Points:

Points Range:
5 (5.00%) - 5 (5.00%)
The student provides an accurate, clear, and complete
description of the chief complaint and history of present illness.
Feedback:
Points:

Points Range:
4 (4.00%) - 4 (4.00%)
The student provides an accurate description of the chief
complaint and history of present illness.
Feedback:
Points:

Points Range:
0 (0.00%) - 0 (0.00%)
Feedback:
Points:
3 (3.00%)
Points Range:
0 (0.00%) - 3 (3.00%)

The student provides a vague, inaccurate, or incomplete
description of the chief complaint and history of present illness,
or description is missing.
Feedback:
Description of past psychiatric, substance use, medical, social,
and family history
Points:

Points Range:
5 (5.00%) - 5 (5.00%)
description of past psychiatric, substance use, medical, social,
and family history.
Feedback:
Points:
4 (4.00%)

Points Range:
4 (4.00%) - 4 (4.00%)
The student provides an accurate description of past
psychiatric, substance use, medical, social, and family history.
Feedback:
Points:

Points Range:
0 (0.00%) - 0 (0.00%)
Feedback:
Points:
Points Range:
0 (0.00%) - 3 (3.00%)

description of psychiatric, substance use, medical, social, and
family history, or description is missing.
Feedback:
Discussion of most recent mental status exam and observations
made during interview and review of systems
Points:

Points Range:
14 (14.00%) - 15 (15.00%)
discussion of results from most recent mental status exam and
observations made during interview and review of systems.
Feedback:
Points:

Points Range:
12 (12.00%) - 13 (13.00%)
The student provides an accurate discussion of results from
most recent mental status exam and observations made during
interview and review of systems.
Feedback:
Points:
11 (11.00%)

Points Range:
11 (11.00%) - 11 (11.00%)
Feedback:
Points:

Points Range:
0 (0.00%) - 10 (10.00%)
All or most of the discussion is inaccurate or missing.
Feedback:
Discussion of diagnostics with results
Points:

Points Range:
9 (9.00%) - 10 (10.00%)
discussion of diagnostics with results.
Feedback:
Points:
8 (8.00%)

Points Range:
8 (8.00%) - 8 (8.00%)
The student provides an accurate discussion of diagnostics
with results.
Feedback:
Points:
Points Range:

7 (7.00%) - 7 (7.00%)
Feedback:
Points:
Points Range:
0 (0.00%) - 6 (6.00%)

Feedback:
Diagnosis with three (3) differentials
Points:
Points Range:

23 (23.00%) - 25 (25.00%)
diagnosis with three (3) differentials.
Feedback:
Points:
22 (22.00%)
Points Range:
20 (20.00%) - 22 (22.00%)

The student provides an accurate diagnosis with three (3)
differentials.
Feedback:
Points:
Points Range:
18 (18.00%) - 19 (19.00%)

The student provides a vague, inaccurate, less than 3 or
incomplete diagnosis with differentials.
Feedback:
Points:
Points Range:
0 (0.00%) - 17 (17.00%)

All or most of the discussion is inaccurate or missing. Less
than 2 diagnosis.
Feedback:
Comprehensive Psychiatric Evaluation documentation
Points:
Points Range:
23 (23.00%) - 25 (25.00%)

The response clearly, accurately, and thoroughly follows the
Comprehensive Psychiatric Evaluation format to document the
selected patient case.
Feedback:
Points:
22 (22.00%)
Points Range:
20 (20.00%) - 22 (22.00%)

The response accurately follows the Comprehensive
Psychiatric Evaluation format to document the selected patient
case.
Feedback:
Points:
Points Range:
18 (18.00%) - 19 (19.00%)

The response follows the Comprehensive Psychiatric
Evaluation format to document the selected patient case, with
some vagueness and inaccuracy.
Feedback:
Points:
Points Range:
0 (0.00%) - 17 (17.00%)

The response incompletely and inaccurately follows the
Feedback:
Presentation style
Points:
5 (5.00%)

Points Range:
5 (5.00%) - 5 (5.00%)
Presentation style is exceptionally clear, professional, and
focused.
Feedback:
Points:

Points Range:
4 (4.00%) - 4 (4.00%)
Presentation style is clear, professional, and focused.
Feedback:
Points:
Points Range:
3 (3.00%) - 3 (3.00%)

Presentation style is mostly clear, professional, and focused
Feedback:
Points:
Points Range:
0 (0.00%) - 2 (2.00%)

Presentation style is unclear, unprofessional, and/or
unfocused.
Feedback:
Show Descriptions
Show Feedback
Photo ID display and professional attire--
Levels of Achievement:

Excellent
5 (5.00%) - 5 (5.00%)
Good
0 (0.00%) - 0 (0.00%)
Fair
0 (0.00%) - 0 (0.00%)
Poor
0 (0.00%) - 0 (0.00%)

Feedback:
Time--
Excellent
5 (5.00%) - 5 (5.00%)
Good
0 (0.00%) - 0 (0.00%)

Fair
0 (0.00%) - 0 (0.00%)
Poor
0 (0.00%) - 0 (0.00%)
inclusion.)
Feedback:

Description of chief complaint and history of present illness--
Excellent
5 (5.00%) - 5 (5.00%)
Good
4 (4.00%) - 4 (4.00%)
Fair
0 (0.00%) - 0 (0.00%)

Poor
0 (0.00%) - 3 (3.00%)
Feedback:
and family history--
Excellent
5 (5.00%) - 5 (5.00%)

description of past psychiatric, substance use, medical , social,
and family history.
Good
4 (4.00%) - 4 (4.00%)
The student provides an accurate description of past psychiatric,
substance use, medical, social, and family history.
Fair
0 (0.00%) - 0 (0.00%)
Poor
0 (0.00%) - 3 (3.00%)

Feedback:
made during interview and review of systems--
Excellent
14 (14.00%) - 15 (15.00%)
Good
12 (12.00%) - 13 (13.00%)

Fair
11 (11.00%) - 11 (11.00%)
Poor
0 (0.00%) - 10 (10.00%)
Feedback:

Discussion of diagnostics with results--
Excellent
9 (9.00%) - 10 (10.00%)
Good
8 (8.00%) - 8 (8.00%)
The student provides an accurate discussion of diagnostics with
results.
Fair
7 (7.00%) - 7 (7.00%)

Poor
0 (0.00%) - 6 (6.00%)
Feedback:
Diagnosis with three (3) differentials--
Excellent
23 (23.00%) - 25 (25.00%)
The student provides an accurate, clear, and complete diagnosis

with three (3) differentials.
Good
20 (20.00%) - 22 (22.00%)
differentials.
Fair
18 (18.00%) - 19 (19.00%)
Poor
0 (0.00%) - 17 (17.00%)
All or most of the discussion is inaccurate or missing. Less than
2 diagnosis.

Feedback:
Comprehensive Psychiatric Evaluation documentation--
Excellent
23 (23.00%) - 25 (25.00%)
Good
20 (20.00%) - 22 (22.00%)
The response accurately follows the Comprehensive Psychiatric
Evaluation format to document the selected patient case.

Fair
18 (18.00%) - 19 (19.00%)
Poor
0 (0.00%) - 17 (17.00%)
Feedback:

Presentation style--
Excellent
5 (5.00%) - 5 (5.00%)
focused.
Good
4 (4.00%) - 4 (4.00%)
Fair
3 (3.00%) - 3 (3.00%)

Poor
0 (0.00%) - 2 (2.00%)
Presentation style is unclear, unprofessional, and/or unfocused.
Feedback:
Raw Total: 80.00 (of 100)
Feedback to Learner

please see feedback in your paper.
Name:PRAC_6635_Week7_Assignment2_Rubric

Date: October 8, 2021
To: Billy Gomez, M.D
Zoo Director
The Adventure Zoo Park
From: Ivan Fuentes, Animal Curator
Miguel Ramirez, Zookeeper
Subject: Proposal for a new work routine cycle.
Purpose:
The purpose of our proposal is to request a new system that will
apply to the zookeepers and animal
curators to fully have an area with equal responsibility.
Summary:
On September 20, 2021, Dr. Billy Gomez, TAZP Zoo Director,
filed a complaint to the animal curators and
zookeepers that maintain the health of the animals. Some of us
have noticed that the tasks that are
spread out to each worker are unfair. The tasks consist of
feeding, cleaning, and exhibit maintenance.
There is also diet preparations, behavioral observations, and
record keeping.

Currently, TAZP has no formal task given to one staff member.
By default, some staff members have
taken more responsibility than others. More than half of our zoo
staff leaves the time-consuming tasks
for others to complete. This situation is not ideal because not all
the zoo staff are taking their
responsibilities seriously. This can affect the work environment
for the staff at TAZP.
Therefore, Dr. Gomez wants us to determine the best approach
to make a fair and honest system to all
zoo staff to complete. Specifically, Dr. Gomez asked that we
develop a plan to determine TAZP staff’s
current work schedule system, determine how zoos separate
tasks, and establish a criteria by which we
might evaluate tasks systems for TAZP.
We propose to find a way to divide all tasks required for
zookeepers and animal curators in our zoo
setting and present our findings to Dr. Gomez. To perform this,
we would need to carry our research on
the tasks of the staff. We would need to determine the time and
work it takes for each task, send out
questionnaires to TAZP staff, and interview Dr. Gomez. Then
we would need to collect and analyze the

data into a report.
To complete this research, we will need approximately 15 hours
over the course of 2 weeks. If this
proposal is authorized, we would begin our research
immediately, and we will submit our progress
reports to Dr. Gomez on October 25, 2021.
Introduction:
On September 20, 2021, Dr Billy Gomez, TAZP Zoo Director,
filed a complaint to the animal curators and
zookeepers to create a new and better work environment to
better the stay for any coming visitors to
our zoo.
Currently, TAZP has no form of demanding other zookeepers
and animal curators to separate each task.
Each task requires demanding work and patience. More than
half of our workers complain about the
tasks they are given. This situation is not ideal because The
Adventure Zoo Park is a place for kids and
adults to enjoy. By changing the work system, we can have a
better environment for everyone that
comes to our zoo.

Therefore, Dr. Gomez wants us to determine the best approach
to give a new circular rotation of tasks in
our zoo staff. Specifically, Dr. Gomez wants to divide the
following 4 tasks.
• Diet preparations
• Behavioral observations and record keeping
• Feeding the animals
• Cleaning after the animals
• Have a nice and clean exhibit.
Proposed Program:
With the approval of Dr. Gomez, we would perform the
following 3tasks to create a new work system
for the staff at TAZP.
Task 1. Acquire an understanding of what the tasks the
zookeepers and animal curators do across the
exhibit.
We (Ivan Fuentes and Miguel Ramirez) have both noticed the
complaints of our fellow zookeeper and
animal curators. We have seen that there are a few of our staff
that undergo more responsibility than
others do.

We suggest that we take time throughout our two weeks to
question each zookeeper and animal
curators. With the questionnaire, we will determine how much
time each task takes and the positives
and negatives of our current system. Our current system
determines the integrity of our staff.
Task 2. Establish a criteria for the staff
Establishing a new system will take time and money away from
TAZP. The criteria will give our staff
more responsibility to those who have taken advantage of the
old system. It will also take responsibility
of those who have taken more than they can handle.
The criteria will consist of the health of the animals and the
environment of the zoo.
Task 3. Create a circular task system
The new system that we recommend will take time to get
established. We will need to determine each
task and create a system that rotates daily. This will give all our
staff at TAZP each responsibility and
tasks throughout their week.
Qualifications and Experiences:
We are both experienced staff members that have been working

under The Adventure Zoo Park
numerous years.
• Ivan Fuentes, Animal Curator, holds a bachelors in biological
science. He has served at The
Adventure Zoo Park for over 19 years. He has taken care of all
the animals’ heath. The health of
the animals has attracted more of the public to visit the zoo. He
oversees over 60 animals'
health and environment. He has provided leadership in the staff
of the zoo.
• Miguel Ramirez, Zookeeper, has overseen the exhibits
wellbeing. He has work for The Adventure
Zoo Park for 15 years and provided the zoo a clean area for the
animals and the people. He has
completed more than half of the tasks that is required for a
regular zookeeper.
Budget:
Name Hours Hourly Rate (S) Cost ($)
Ivan Fuentes 15 30 450
Miguel Ramirez 15 21 315

Total: $765
4
Proposal Request for proposal: New company websiteOctober
11, 2021,
Mrs. Matilda Storm,
Gems Galore Jewelry,
Parker streets, London
UK, E1 7BS
Dear, Mrs. Matilda
I, John Wick, the senior chief web officer of Gems Galore
Jewelry, am writing to present a business project, which is
mutually beneficial for the organization and will enable an
increase in our online sales, increase organization awareness,
present an image that is professional and modern, engage and
expand our customer base. I am writing in request of support
with grand amount of $50,000. The purpose for this grant is for
completion of the phase 1 of the project.Overview The vision
for this project is to develop a website that will help increase
the organization’s customer base and improve marketing
methods IntroductionBackground
The organization have developed and created loyal customers
base in London for the past few years. However, most of the
customers age 35years and below, few customers are aged above
35 years and shop with Gems Galore Jewelry in-store. With
more customers shopping online, I believe there is a great
opportunity to increase as well as expand the customer base
beyond our local area. Furthermore, the first website the
organization developed in 2017 using free online template has
remained unchanged till today and it looks unrefined as well as

very dated. In addition it is not compatible with mobile as the
new website the organization would need.
Proposed program
Description of project
The new website would be mobile-compatible, accessible to all
individuals including the once with low vision and stylish. It
will include:
· A page showing company’s history;
· Link to all company’s social media profile
· A blog that will be used to update customers on the business
and jewelries through content management system
· Ecommerce store, which accepts all major credit cards
including PayPal
· Contact page with company’s email, online contact form and
telephone number.
In this project, I would be responsible for copywriting and
content strategy, which includes;
· Optimization of mobile device and search engine
· Visual design
· Site graphics and customer service portal
· Software platform, which includes Front-end and back-end
coding
· Limited vision users accessibility
· Training and technical support
· Testing as well as quality assurance
Timeline
I am ready to start this project on October 20, 2021. The
process takes 7-9weaks, which depends on how fast I get the
approval at each level or point. So, the new website is expected
to be ready for testing and launching in the beginning of
January, 2022.
Budget
For this new website am budgeting for $20,000- $30,000, with
potential addition of $15, 000 for digital marketing and social
media components and $5, 000 for other expenses such as

training and testing.
Qualification and experience
I have an exceptional track record as a website developer and
designer and have always worked and pushed to produce
reliable, innovate and responsive websites. I have developed
more than 10 websites in the past one year, with 5 years’
experience.
Week 7: Comprehensive Psychiatric Evaluation And Patient
Case Presentation
Catherine Nwosu
Master of Science in Nursing, Walden University
NRNP 6635-24: Psychopathology and Diagnostic Reasoning
Dr. Tabitha Perrigo
October 17, 2021
Comprehensive Psychiatric Evaluation And Patient Case
Presentation
Schizophrenia refers to a serious mental health disorder in
which individuals have

problems interpreting reality in a normal way (McCutcheon et
al., 2019). Schizophrenia
involves a mix of delusions, hallucinations, and extreme
disordered thinking and behavior
that can impact the daily functioning of an individual.
Individuals with Schizophrenia often
require lifelong treatment because the disorder impacts their
ability to think, feel, and
behave clearly (McCutcheon et al., 2019). It is difficult to
identify a specific cause of
Schizophrenia although it is believed to result from a
combination of genetics, altered
brain chemistry and structure, and environmental causes
(Fond et al., 2021).
Characteristics of Schizophrenia include thoughts or
experiences that seem to be out of
touch with reality and reduced participation in daily activities.
Treatment for Schizophrenia
often works by combining several strategies as
psychotherapy, medications, and
coordinated specialty care services (Fond et al., 2021).
Schizophrenia falls under
psychotic disorders and it affects less than 1% of individuals in
the United States (Fond et

al., 2021).
Conducting a comprehensive evaluation during the assessment
and diagnosis of
patients with Schizophrenia is important to pinpoint the
exact factors that point to
Schizophrenia as the primary diagnosis. This paper is
aimed at constructing a
comprehensive psychiatric evaluation that comprises of
differential diagnosis and
reflection notes about a patient who is presenting with
symptoms of Schizophrenia.
CC (chief complaint): " I have lots of issues at work and it is
stressing me out.”
HPI: The patient is a 39-year-old female who presents to the
clinic via telehealth with
consent obtained complaints of having lots of issues at work
which stress her out. The
© 2020 Walden University Page 2 of 10
Tabitha Perrigo DNP PMHNP
Good clear chief complaint
patient explains that she is currently seeing a new
psychiatrist because her previous

provider does not accept health insurance anymore. The patient
explains that she has a
history of a past diagnosis of Schizophrenia in 2018 after
having an episode. She
explains that the job she had during that time presented some
issues that significantly
contributed to her symptoms. She admits to being admitted to a
psychiatric hospital in
2018 where the diagnosis of Schizophrenia was made. The
patient was initially
prescribed Zoloft 20MG together with injections of Aristada for
1.5 years. However, she
explains that she stopped taking the injections because she
could not afford it. Recently,
the patient began taking Risperidone 2MG. Other current
medications include
Risperidone 2 MG Oral Tablet, Fluoxetine HCl 20 MG Oral
Capsule, and Benztropine
Mesylate 1 MG Oral Tablet. Her father has dementia and
no other medical issue is
reported about other family members.
Past Psychiatric History:
al Statement: The patient has a previous diagnosis of
Schizophrenia that

was done in 2018.
a psychiatric facility.
s: Risperidone 2 MG Oral Tablet,
Fluoxetine HCl 20 MG Oral
Capsule, and Benztropine Mesylate 1 MG Oral Tablet.
He provided her past history but no actual current symptoms
that brought her in for today's visit the HPI as a history of
present illness do you want to include the information you did
but what are the current signs and symptoms that she's
presenting with how often are they occurring how severe are
they what makes it better what makes it worse.
patient has a previous
psychiatric diagnosis of schizophrenia that was done in
2018 during her
hospitalization.
Substance Current Use and History: explains that she does not
smoke although she

admits to social drinking at least twice a year.
Family Psychiatric/Substance Use History: father has dementia
although apart from
this, there is no other medical health issues reported regarding
the other family members.
Psychosocial History: The patient had a normal birth and grew
up with both parents.
She obtained her GE and has two siblings. She enjoys going to
the movies, watching TV,
and shopping. The patient is a Christian and she explains that
she has good appetite.
She admits to being straight or heterosexual and identifies
as a female. The patient
explains to having a difficult time maintaining her job
although she works for a temp
agency currently and it seems to be going well. The patient is
not in a relationship and
denies any sexual activity. She lives alone and the nature of the
relationship between her
and her siblings is not provided.
Medical History: Schizophrenia
Oral Tablet,
Fluoxetine HCl 20 MG Oral

Capsule, and Benztropine Mesylate 1 MG Oral Tablet.
allergies.
What about other substances such as Hallucinogenics
methamphetamines caffeine cocaine those type of medication
you need to be sure to document a clear substance use history
Did she have any psychotherapy or therapist or was her only
treatment medication?
ROS:
weakness, or fatigue.
vision, or yellow sclerae.
Does not have hearing loss, sneezing, congestion, runny nose,
or sore throat.
discomfort, or chest

pressure. Does not have palpitations or edema.
gh, or
sputum.
diarrhea.
urination; the color is
standard; has normal odor.
seizures, tremors, ataxia,
paralysis, numbness, or tingling in the extremities.
pain, joint pain, or
stiffness.
bleeding.
history of
splenectomy.

cold, or heat intolerance.
Does not have polydipsia or polyurea.
Physical exam: VITAL SIGNS
Height: 5’9”
Weight; 154 lbs.
BP: 138/76
Temperature: 97.3F
Pulse: 88
Respiratory rate: 20
O2 Saturation: 98%
Pain: No complaint of pain verbalized during evaluation.
Diagnostic tests/results:
Patient Health Questionnaire screening was administered which
is a diagnostic
instrument for assessing common mental disorders. It is
specifically used in assessing
whether the symptoms presented are in correspondence to those
of depression.
Blood tests or MRI could also be used by the provider to rule
out any medical conditions.

What specific blood test would you want to order why and what
evidence supports it
White scholarly sources support the use of the patient health
questionnaire?
Assessment
Mental Status Examination:
The patient is a 39-year-old female who looks her stated age.
She is oriented to
person, place, time and situation and her general appearance is
neat and clean. The
patient has a normal eye contact and psychomotor activity
involves repetitive movements.
Her attention is intact and she is cooperative with the examiner.
The patient has a normal
speech with a euthymic mood and appropriate affect to her
mood. Her thought process is
goal-directed and her thought content is intact. The patient has
good perception and
insight with fair judgment and cognition. Her language is
appropriate and she has good

immediate, recent, and remote memory. The patient has no
suicidal or homicidal
ideations.
Differential Diagnoses:
Schizophrenia
The most likely primary diagnosis for this patient is
Schizophrenia. This is because she
has a history of previous diagnosis of Schizophrenia in 2018. It
is likely that the patient is
undergoing a relapse of Schizophrenia because according to
research, symptoms of
Schizophrenia can get better when it is under control but the
individual may undergo a
relapse and the symptoms will come back if it is no longer
controlled (Lieberman & First,
2018). This is true for this patient because after being
diagnosed with Schizophrenia , she
was put on Zoloft 20MG and was getting injections of Aristada
for 1.5 years but later on
stopped taking the injections due to her inability to afford it.
The failure to take medicine

This is a patient who carries a diagnosis of schizophrenia but
you do not assess or if specifically address if hallucinations are
delusional thought processes are present this is a requirement of
assessing a patient with a history of schizophrenia but a
assessment should always include if hallucinations or psychotic
symptoms are present.
as instructed is the most common cause of any relapses in
Schizophrenia and is likely to
be the case of the patient (Fond et al., 2021).
Schizoaffective Disorder
This is also a possible diagnosis for the patient because the
symptoms for this condition
often resemble those of Schizophrenia with the addition of
mood symptoms (Boerrigter et
al., 2017). However, this diagnosis can be ruled out because the
symptoms of the patient
are better explained by Schizophrenia disorder especially due
to the fact that the patient
has a history of the disorder.
Bipolar Disorder
This is a possible diagnosis for this patient because the patient’s
symptoms of having

issues at work that stress her out resemble those of bipolar
disorder. This is because
individuals with bipolar disorder are more prone to stress and
they have a hard time
recovering from, and adjusting to stressors (Grande et al.,
2016). Also, the symptoms for
this disorder are similar to those of Schizophrenia and
Schizoaffective disorder making it
a possible diagnosis (Grande et al., 2016). However, the
diagnosis is ruled out because
the patient does not report periods of elevated moods and mania
or depression which is
characteristic of this condition (Fond et al., 2021). Also, the
patient’s a previous history of
Schizophrenia explains her symptoms better.
Plan of Care
The plan includes strategies of continuing to stabilize the
symptoms of
Schizophrenia in the next 90 days. It also involves encouraging
the patient to complete a
physical and get yearly labs and to adopt positive coping skills
such as walking,

What signs and symptoms of schizophrenia was she presenting
with at the time of the evaluation
journaling, and deep breathing exercises (Fond et al., 2021).
The plan of care also
involves encouraging the patient to call 911 in the event of
suicidal or homicidal ideations.
Patient is to follow up in two weeks.
Reflections:
In order to successfully controls Schizophrenia, it is important
to combine several
approaches such as the use of psychotherapy, medication, and
behavioral therapy. It is
important to understand the relapses in Schizophrenia in detail
and how they occur. An
element that I would do differently would be obtaining
more information about the
patient’s previous psychiatric hospitalization in 2018. One
ethical consideration that I
would apply in the case of the patient is establishing a
background of her financial
situation to understand reasons that made her unable to afford

taking the injections and
her current financial position regarding her ability to obtain
prescribed medication.
Conclusion
Schizophrenia is well controlled when a patient is adhering to
the treatment plan
including taking the medication because this prevents relapses.
It is important to advise
the patient on the possible side effects of the medication and
how to manage them. It is
also significant to assess the prescribed medications for
the patient and the possible
contraindications that may occur.
References
Boerrigter, D., Weickert, T. W., Lenroot, R., O’Donnell, M.,
Galletly, C., Liu, D., ... &
Weickert, C. S. (2017). Using blood cytokine measures to
define high inflammatory
biotype of schizophrenia and schizoaffective disorder. Journal
of

neuroinflammation, 14(1), 1-15.
Fond, G., Pauly, V., Leone, M., Llorca, P. M., Orleans, V.,
Loundou, A., ... & Boyer, L.
(2021). Disparities in intensive care unit admission and
mortality among patients
with schizophrenia and COVID-19: a national cohort study.
Schizophrenia
bulletin, 47(3), 624-634.
Grande, I., Berk, M., Birmaher, B., & Vieta, E. (2016). Bipolar
disorder. The
Lancet, 387(10027), 1561-1572.
Lieberman, J. A., & First, M. B. (2018). Psychotic disorders.
New England Journal of
Medicine, 379(3), 270-280.
McCutcheon, R. A., Abi-Dargham, A., & Howes, O. D. (2019).
Schizophrenia, dopamine
and the striatum: from biology to symptoms. Trends in
neurosciences, 42(3), 205-
220.

Week 5: Comprehensive Psychiatric Evaluation And Patient
Case Presentation
Catherine Nwosu
Master of Science in Nursing, Walden University
NRNP 6635-24
Dr. Tabitha Perrigo
September 1, 2021
Comprehensive Psychiatric Evaluation And Patient Case
Presentation
Stress and pressure that individuals face from circumstances
such as their jobs or
homes can have significant effects on their mental health
(English et al., 2018). This
pressure may become overwhelming and increase the risk of an
individual developing a
mental health problem (English et al., 2018). The pressure can
result in other effects such
as sleep disturbances or difficulty in eating which are also
indications of underlying mental
health problems (English et al., 2018). The purpose of
this paper is to conduct a

comprehensive psychiatric evaluation based on a patient under
similar circumstances.
The paper will discuss objective, subjective, assessment, and
reflection notes data.
CC (chief complaint): "I have lots of pressure at home and at
work".
HPI: The patient is a 41-year- old Hispanic female presenting
for initial evaluation with
complaints of having lots of pressure at home and at work. The
patient explains that she
does not feel very good and even though she tries to concentrate
at work, she never gets
enough sleep and barely eats much. The patient explained
that she has mood
fluctuations with her mood going up and down causing her to
sometimes cry herself to
sleep. She explains that this is an issue that she has struggled
with for some time now but
does not give the specific duration. The patient is currently
taking Mirtazapine 15 MG oral
tablet daily at bedtime. She explains that she does not smoke
nor does she abuse any
other substance and her past medical history includes
mood issues. She is married

although her husband still resides in Mexico and she
currently lives in the state of
Maryland. There is no report of a history of trauma and
she denies any suicidal or
At the top of your HPI even though this is an initial evaluation
with you obviously this patient has a previous diagnosis in
history you would want to begin your HPI with patient presents
today for an initial evaluation with this provider but carries a
diagnosis of depression that she started medication for one year
ago two years ago however long that he is re-organize your HPI
and write it in chronological order. When the symptoms first
began if there's a diagnosis if there's medication what symptoms
are currently going on what order did they present how long
have they been present
Including the beginning at the top of the HPI if she's currently
taking medication for how long and who prescribed it and what
is it prescribed for
Follow up with a question if you had to estimate how long is
this been going on has it been going on at least a month two
months specifying the duration is important to justifying your
diagnosis
Are the mood fluctuations over the course of a single day does
she have an up mood for a week and then a down mood for a

week these are questions you need to clarify on an HPI because
this indicates whether the presence of depression personality
disorders versus a bipolar disorder.
The patient reports decrease in appetite lack of sleep and poor
concentration. Keep in mind that you want to present the
symptoms and his few of words as possible there is more value
in being clear and concise than wordy.
Good clear yet brief chief complaint good job
homicidal ideations or plans. The patient does not have visual
auditory hallucinations,
paranoia, or delusions.
with mood issues.
ildren.
Mirtazapine15 MG orally at bedtime.
patient has a previous
psychiatric diagnosis of mood issues

Substance Current Use and History: the patient denies the use of
any substance both
currently and historically.
Family Psychiatric/Substance Use History: the patient's brother
has mood problems.
No other member of the patient’s family is reported to have any
disorder.
Psychosocial History: The patient is working although there is
no specification of her
occupation. The patient explains that she has been working
for 17 years and has
managed to foster a good relationship with her peers. She lives
in the state of Maryland
and has four children aged 21, 13, and 6-year old twins. The
patient raises the children
alone and reports that she is married but the husband is still in
their country of origin
which is Mexico. The patient had normal birth and explains that
she is heterosexual.
What is her educational background did she attend school does
she have a good relationship with her children a good
psychosocial history can provide you with much information not

only for the diagnosis but for potential therapies down the road
Be sure to clearly document if there's a family history of
completed suicide or violence
Who prescribed this medication when where and for watt
Be specific what type of mood issues that is vague
Medical History:
: there are no known drug, food, or environmental
allergies for the
patient.
ROS:
eating. Does not have
weight loss, fever, chills, weakness, or fatigue.
ENT: Does not have visual loss, blurred vision, double
vision, or yellow sclerae.
Does not have hearing loss, sneezing, congestion, runny nose,
or sore throat.

est
discomfort, or chest
pressure. Does not have palpitations or edema.
sputum.
have vomiting, nausea,
or diarrhea.
You can include hear the number of births that she's given has
she had any miscarriages were her pregnancies normal where
they traumatic go further detail with your reproductive history
: does not have burning sensation during
urination; the color is
standard; has normal odor.
seizures, tremors, ataxia,
paralysis, numbness, or tingling in the extremities.
t have muscle pain, back

pain, joint pain, or
stiffness.
bleeding.
history of
splenectomy.
g,
cold, or heat intolerance.
Does not have polydipsia or polyurea.
Physical exam: VITAL SIGNS
Height: 5’6”
Weight: 272 lbs.
Blood Pressure: 132/68
Temperature: 97.3
Pulse: 76
Respiratory rate: 18
O2 Saturation: 98
Pain: No pain

It's generally a good idea to include a statement such as the
patient displays no acute distress
Diagnostic tests/results:
Hamilton Rating Scale for Depression
This is a diagnostic test that the care provider can use to assess
whether the symptoms
presented are in correspondence to those of depression. The test
is offered as a multiple
choice questionnaire and it rates the presence and severi ty of
the depression of the
patient.
Insomnia-Interview questions
Since there is no specific test for diagnosing insomnia, a care
provider can perform a
physical exam together with interview questions about specific
sleep problems and
symptoms to identify whether the symptoms presented by the
patient point to insomnia as
the diagnosis.
Assessment

The patient is a 41-year-old Hispanic female who looks her
stated age. She is
calm and cooperative with the examiner and has good eye
contact. She has the ability of
verbally responding to questions appropriately with intact
memories. She is well dressed
and appropriate to the occasion. There is no evidence of any
abnormal motor activity.
The speech of the patient is clear, coherent, and normal in
volume and tone. The mood is
euthymic and affect is congruent with mood. She has coherent,
goal directed, and linear
thought process. There is no evidence of looseness of
association or flight of ideas. The
patient denies auditory or visual hallucinations. There is no
evidence of any delusional
thinking. The patient denies having suicidal or homicidal
ideations. Judgment and
Good choice of assessment tools

cognition are good and her insight is very good as well.
Patient’s recent and remote
memory is intact.
1. Major Depressive Disorder
Based on the symptoms of the patient, this appears to be the
most likely primary
diagnosis. DSM 5 criteria describes Major Depressive Disorder
as persistent feelings of
sadness with symptoms including depressed mood most of the
day nearly every day, a
decrease in appetite, and sleep disturbances (Hasin et al., 2018).
These symptoms are
present in the patient because she states feeling sad and
sometimes crying herself to
sleep, failing to get enough sleep, and having problems eating.
Additionally, the patient
explains that she has a lot of pressure at home and at work.
Research has reported that
when an individual has a lot of pressure whether at home or at
work and they do not cope
well with this pressure, the risk of developing depression is
increased (Balcombe & De

Leo, 2021). This is likely to be the case of the patient. Also, it
is reported by research that
if a family member has a mood disorder then this highly
increases the risk of an individual
developing depression (Hasin et al., 2018). In the patient’s case,
her brother has mood
problems which increases her risk for developing depression.
2. Insomnia
Insomnia is a possible diagnosis for this patient because the
patient’s symptoms
correspond with those of insomnia. Insomnia is described by
DSM 5 as the inability to get
satisfactory quantity or quality of sleep (Riemann et al., 2020).
This is evident in the case
of the patient because she states that she does not sleep good at
all. Also, it is reported
by research that being under pressure can impact the mental or
physical health of an
individual hence disrupting sleep (Riemann et al., 2020). This
goes ahead to cause

temporary or chronic insomnia depending on their severity of
the pressure or stress
(Riemann et al., 2020). This is true in the case of the patient
because she admits to facing
a lot of pressure from her home and work. However, this
diagnosis is ruled out because
insomnia can only be considered a primary diagnosis when the
symptoms are not better
explained by other mental disorders yet in this case, sleeping
problems and decreased
appetite are mainly associated with depression (Zimmerman et
al., 2019).
3. Generalized Anxiety Disorder
This is considered a likely diagnosis for this patient because of
how her symptoms
resemble those of the GAD disorder. According to DSM 5, sleep
difficulties maybe an
indication of this condition because they may be caused by
pressure and stress from job
responsibilities or performance, family issues, financial matters,
and other life
circumstances (Saulnier, et al., 2021). This is true for the
patient because she admits to
being under a lot of pressure at home and at work as well as not

being able to sleep well.
However, the diagnosis is ruled out because there are no reports
of excessive worry even
when there is no specific threat, which is the main characteristic
diagnosis of this
condition (Saulnier, et al., 2021). Additionally, these symptoms
can be better explained by
another medical condition which is Major Depressive Disorder.
Plan of Care
The plan of care is aimed at maintaining stability from
depression, poor appetite,
and insomnia in the course of the next 90 days. The plan
includes continuing Mirtazapine
15 MG, educating the patient on medication and interactions,
educating the patient on
using positive coping skills, instructing the patient to report any
medication side effects,
encouraging the patient to engage in healthy lifestyle,
conducting follow up of the patient
in two weeks, and asking the patient to call 911 in case of
suicidal or homicidal ideations.

Reflections:
This patient case has reinforced my knowledge regarding how
sleep disturbances
can be a symptom in several conditions and pressure from work
or home can be a
contributing factor to the development of various mental
conditions. It is, therefore,
important to consider additional symptoms before making a
diagnosis. What I would do
differently is asking about more information regarding the mood
issue listed in the
patient’s past medical history so that it is narrowed down to the
specific mood issues as
well as the mood problems faced by the brother. An ethical
consideration at this point
would be ensuring that the medication prescribed to the patient
does not have side
effects which may limit the ability of the patient to perform
daily tasks because she is
working and has four children to take care of all by herself.
Conclusion
The comprehensive psychiatric evaluation above has reviewed
all the information

that is relevant in assessing the case of the patient and making
the accurate diagnosis. It
is evident that while the patient may be showing symptoms of a
certain condition, the
symptoms may be found in another condition as well. Therefore,
it is important to carry
out diagnostic tests so that all the inaccurate diagnoses can be
ruled and the accurate
diagnosis can be confirmed. Additionally, there is need to
consider the various possible
ethical elements which can be applicable in the case. This will
help to ensure that the
evaluation and treatment process of the patient is carried out in
a way that abides by the
ethical guidelines and principles found in healthcare.
Catherine, overall you did a good job there's a few areas you
need to work at digging in a little further but keep working
References
Balcombe, L., & De Leo, D. (2021). Digital mental health
challenges and the horizon

ahead for solutions. JMIR Mental Health, 8(3).
English, D., Rendina, H. J., & Parsons, J. T. (2018). The effects
of intersecting stigma: A
longitudinal examination of minority stress, mental health, and
substance use
among Black, Latino, and multiracial gay and bisexual men.
Psychology of
violence, 8(6), 669.
Hasin, D. S., Sarvet, A. L., Meyers, J. L., Saha, T. D., Ruan, W.
J., Stohl, M., & Grant, B.
F. (2018). Epidemiology of adult DSM-5 major depressive
disorder and its
specifiers in the United States. JAMA psychiatry, 75(4), 336-
346.
Riemann, D., Krone, L. B., Wulff, K., & Nissen, C. (2020).
Sleep, insomnia, and
depression. Neuropsychopharmacology, 45(1), 74-89.
Saulnier, K. G., Allan, N. P., Judah, M. R., Koscinski, B.,
Hager, N. M., Albanese, B., ... &
Schmidt, N. B. (2021). Attentional Control Moderates the

Relations between
Intolerance of Uncertainty and Generalized Anxiety Disorder
and
Symptoms. Cognitive Therapy and Research, 1-9.
Zimmerman, M., Martin, J., McGonigal, P., Harris, L., Kerr, S.,
Balling, C., ... & Dalrymple,
K. (2019). Validity of the DSM‐ 5 anxious distress specifier for
major depressive
disorder. Depression and anxiety, 36(1), 31-38.
Catherine NwosuMaster of Science in Nursing, Walden
University
PLEASE FOLLOW THE INSTRUCTIONS AS INDICATED
BELOW:
1). ZERO (0) PLAGIARISM.
2). AT LEAST 5 REFERENCES, NO MORE THAN 5 YEARS
(WITHIN 5YRS, OR LESS THAN 5YRS)
3). PLEASE SEE THE ATTACHED RUBRIC DETAILS,
Comprehensive Psychiatric Evaluation Exemplar,
Comprehensive Psychiatric Evaluation Template, Patient
History Report, Assignment question. Feedback from weeks 5 &
7 to be incooperated into this assignment.
4). Please review and follow the grading rubric details, and
include each component in the assignment as required. Also,

follow the APA 7 writing rules and style/Format.
Thank you.
Week (enter week #): (Enter assignment title)
Student Name
College of Nursing-PMHNP, Walden University
NRNP 6635: Psychopathology and Diagnostic Reasoning
Faculty Name
Assignment Due Date
NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation
Template
CC (chief complaint):
HPI:
· General Statement:
· Caregivers (if applicable):
· Hospitalizations:
· Medication trials:
· Psychotherapy or Previous Psychiatric Diagnosis:
Substance Current Use and History:
Family Psychiatric/Substance Use History:
Psychosocial History:
Medical History:
· Current Medications:
· Allergies:

· Reproductive Hx:
ROS:
· GENERAL:
· HEENT:
· SKIN:
· CARDIOVASCULAR:
· RESPIRATORY:
· GASTROINTESTINAL:
· GENITOURINARY:
· NEUROLOGICAL:
· MUSCULOSKELETAL:
· HEMATOLOGIC:
· LYMPHATICS:
· ENDOCRINOLOGIC:
Physical exam: if applicable
Diagnostic results:
Assessment
Reflections:
References
© 2020 Walden University
Page 1 of 3
NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation
Exemplar
(The comprehensive evaluation is typically the initial new
patient evaluation. You will practice writing this type of note in

this course. You will be ruling out other mental illnesses so
often you will write up what symptoms are present and what
symptoms are not present from illnesses to demonstrate you
have indeed assessed for all illnesses which could be impacting
your patient. For example, anxiety symptoms, depressive
symptoms, bipolar symptoms, psychosis symptoms, substance
use, etc.)
CC (chief complaint): A brief statement identifying why the
patient is here. This statement is verbatim of the patient’s own
words about why presenting for assessment. For a patient with
dementia or other cognitive deficits, this statement can be
obtained from a family member.
HPI: Begin this section with patient’s initials, age, race, gender,
purpose of evaluation, current medication and referral reason.
For example:
N.M. is a 34-year-old Asian male presents for psychiatric
evaluation for anxiety. He is currently prescribed sertraline
which he finds ineffective. His PCP referred him for evaluation
and treatment.
Or
P.H., a 16-year-old Hispanic female, presents for psychiatric
evaluation for concentration difficulty. She is not currently
prescribed psychotropic medications. She is referred by her
therapist for medication evaluation and treatment.
Then, this section continues with the symptom analysis for your
note. Thorough documentation in this section is essential for
patient care, coding, and billing analysis.
Paint a picture of what is wrong with the patient. This section
contains the symptoms that is bringing the patient into your
office. The symptoms onset, duration, frequency, severity, and
impact. Your description here will guide your differential
diagnoses. You are seeking symptoms that may align with many

DSM-5 diagnoses, narrowing to what aligns with diagnostic
criteria for mental health and substance use disorders.
Past Psychiatric History: This section documents the patient’s
past treatments. Use the mnemonic Go Cha MP.
General Statement: Typically, this is a statement of the patients
first treatment experience. For example: The patient entered
treatment at the age of 10 with counseling for depression during
her parents’ divorce. OR The patient entered treatment for detox
at age 26 after abusing alcohol since age 13.
Caregivers are listed if applicable.
Hospitalizations: How many hospitalizations? When and where
was last hospitalization? How many detox? How many
residential treatments? When and where was last
detox/residential treatment? Any history of suicidal or
homicidal behaviors? Any history of self-harm behaviors?
Medication trials: What are the previous psychotropic
medications the patient has tried and what was their reaction?
Effective, Not Effective, Adverse Reaction? Some examples:
Haloperidol (dystonic reaction), risperidone
(hyperprolactinemia), olanzapine (effective, insurance wouldn’t
pay for it)
Psychotherapy or Previous Psychiatric Diagnosis: This section
can be completed one of two ways depending on what you want
to capture to support the evaluation. First, does the patient
know what type? Did they find psychotherapy helpful or not?
Why? Second, what are the previous diagnosis for the client
noted from previous treatments and other providers. Thirdly,
you could document both.
Substance Use History: This section contains any history or
current use of caffeine, nicotine, illicit substance (including
marijuana), and alcohol. Include the daily amount of use and
last known use. Include type of use such as inhales, snorts, IV,
etc. Include any histories of withdrawal complications from

tremors, Delirium Tremens, or seizures.
Family Psychiatric/Substance Use History: This section contains
any family history of psychiatric illness, substance use
illnesses, and family suicides. You may choose to use a
genogram to depict this information. Be sure to include a
reader’s key to your genogram or write up in narrative form.
Social History: This section may be lengthy if completing an
evaluation for psychotherapy or shorter if completing an
evaluation for psychopharmacology. However, at a minimum,
please include:
Where patient was born, who raised the patient
Number of brothers/sisters (what order is the patient within
siblings)
Who the patient currently lives with in a home? Are they single,
married, divorced, widowed? How many children?
Educational Level
Hobbies:
Work History: currently working/profession, disabled,
unemployed, retired?
Legal history: past hx, any current issues?
Trauma history: Any childhood or adult history of trauma?
Violence Hx:Concern or issues about safety (personal, home,
community, sexual (current & historical)
Medical History: This section contains any illnesses, surgeries,
include any hx of seizures, head injuries.
Current Medications: Include dosage, frequency, length of time

used, and reason for use. Also include OTC or homeopathic
products.
Allergies:Include medication, food, and environmental allergies
separately. Provide a description of what the allergy is (e.g.,
angioedema, anaphylaxis). This will help determine a true
reaction vs. intolerance.
Reproductive Hx:Menstrual history (date of LMP), Pregnant
(yes or no), Nursing/lactating (yes or no), contraceptive use
(method used), types of intercourse: oral, anal, vaginal, other,
any sexual concerns
ROS: Cover all body systems that may help you include or rule
out a differential diagnosis. Please note: THIS IS DIFFERENT
from a physical examination!
You should list each system as follows: General:Head: EENT:
etc. You should list these in bullet format and document the
systems in order from head to toe.
Example of Complete ROS:
GENERAL: No weight loss, fever, chills, weakness, or fatigue.
HEENT: Eyes: No visual loss, blurred vision, double vision, or
yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing,
congestion, runny nose, or sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure, or chest
discomfort. No palpitations or edema.
RESPIRATORY: No shortness of breath, cough, or sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting, or
diarrhea. No abdominal pain or blood.
GENITOURINARY: Burning on urination, urgency, hesitancy,
odor, odd color
NEUROLOGICAL: No headache, dizziness, syncope, paralysis,
ataxia, numbness, or tingling in the extremities. No change in
bowel or bladder control.
MUSCULOSKELETAL: No muscle, back pain, joint pain, or

stiffness.
HEMATOLOGIC: No anemia, bleeding, or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
ENDOCRINOLOGIC: No reports of sweating, cold, or heat
intolerance. No polyuria or polydipsia.
Physical exam (If applicable and if you have opportunity to
perform—document if exam is completed by PCP): From head
to toe, include what you see, hear, and feel when doing your
physical exam. You only need to examine the systems that are
pertinent to the CC, HPI, and History. Do not use “WNL” or
“normal.” You must describe what you see. Always document in
head-to-toe format i.e., General: Head: EENT: etc.
Diagnostic results: Include any labs, X-rays, or other
diagnostics that are needed to develop the differential diagnoses
(support with evidenced and guidelines).
Assessment
Mental Status Examination: For the purposes of your courses,
this section must be presented in paragraph form and not use of
a checklist! This section you will describe the patient’s
appearance, attitude, behavior, mood and affect, speech, thought
processes, thought content, perceptions (hallucinations,
pseudohallucinations, illusions, etc.)., cognition, insight,
judgment, and SI/HI. See an example below. You will modify to
include the specifics for your patient on the above elements —
DO NOT just copy the example. You may use a preceptor’s way
of organizing the information if the MSE is in paragraph form.
He is an 8-year-old African American male who looks his stated
age. He is cooperative with examiner. He is neatly groomed and
clean, dressed appropriately. There is no evidence of any
abnormal motor activity. His speech is clear, coherent, normal
in volume and tone. His thought process is goal directed and
logical. There is no evidence of looseness of association or
flight of ideas. His mood is euthymic, and his affect appropriate
to his mood. He was smiling at times in an appropriate manner.
He denies any auditory or visual hallucinations. There is no

evidence of any delusional thinking. He denies any current
suicidal or homicidal ideation. Cognitively, he is alert and
oriented. His recent and remote memory is intact. His
concentration is good. His insight is good.
Differential Diagnoses:You must have at least three
differentials with supporting evidence. Explain what rules each
differential in or out and justify your primary diagnosis
selection. Include pertinent positives and pertinent negatives for
the specific patient case.
Also included in this section is the reflection. Reflect on this
case and discuss whether or not you agree with your preceptor’s
assessment and diagnostic impression of the patient and why or
why not. What did you learn from this case? What would you do
differently?
Also include in your reflection a discussion related to
legal/ethical considerations (demonstrating 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.).
References
You are required to include at least three evidence-based, peer-
reviewed journal articles or evidenced-based guidelines which
relate to this case to support your diagnostics and differentials
diagnoses. Be sure to use correct APA 7th edition formatting.
© 2020 Walden University
Page 1 of 3
Rubric Detail

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Excellent
Good
Fair
Poor
Photo ID display and professional attire
Points:
Points Range:
5 (5%) - 5 (5%)

Feedback:
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Time
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inclusion.)
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Description of chief complaint and history of present illness

Points:
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5 (5%) - 5 (5%)
Feedback:

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4 (4%) - 4 (4%)
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0 (0%) - 3 (3%)
description of the chief complaint and history of present illnes s,
Feedback:
and family history

Points:
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5 (5%) - 5 (5%)
and family history.
Feedback:

Points:
Points Range:
4 (4%) - 4 (4%)
The student provides an accurate description of past
psychiatric, substance use, medical, social, and family history.
Feedback:

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0 (0%) - 0 (0%)
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0 (0%) - 3 (3%)
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made during interview and review of systems

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14 (14%) - 15 (15%)
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12 (12%) - 13 (13%)
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11 (11%) - 11 (11%)
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Discussion of diagnostics with results

Points:
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9 (9%) - 10 (10%)
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Points:
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8 (8%) - 8 (8%)
The student provides an accurate discussion of diagnostics
with results.
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Points:
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7 (7%) - 7 (7%)
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0 (0%) - 6 (6%)
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Diagnosis with three (3) differentials

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23 (23%) - 25 (25%)
diagnosis with three (3) differentials.
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20 (20%) - 22 (22%)
differentials.
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18 (18%) - 19 (19%)
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0 (0%) - 17 (17%)
All or most of the discussion is inaccurate or missing. Less
than 2 diagnosis.
Feedback:
Comprehensive Psychiatric Evaluation documentation

Points:
Points Range:
23 (23%) - 25 (25%)
Feedback:

Points:
Points Range:
20 (20%) - 22 (22%)
The response accurately follows the Comprehensive
Psychiatric Evaluation format to document the selected patient
case.
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Points:
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18 (18%) - 19 (19%)
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Presentation style

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5 (5%) - 5 (5%)
focused.
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4 (4%) - 4 (4%)
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Points Range:
0 (0%) - 2 (2%)
Presentation style is unclear, unprofessional, and/or
unfocused.
Feedback:

Show Descriptions
Show Feedback
Photo ID display and professional attire--
Excellent
5 (5%) - 5 (5%)
Good
0 (0%) - 0 (0%)
Fair
0 (0%) - 0 (0%)

Poor
0 (0%) - 0 (0%)
Feedback:
Time--
Excellent
5 (5%) - 5 (5%)

Good
0 (0%) - 0 (0%)
Fair
0 (0%) - 0 (0%)
Poor
0 (0%) - 0 (0%)
inclusion.)

Feedback:
Description of chief complaint and history of present illness--
Excellent
5 (5%) - 5 (5%)
Good
4 (4%) - 4 (4%)

Fair
0 (0%) - 0 (0%)
Poor
0 (0%) - 3 (3%)
Feedback:
and family history--

Excellent
5 (5%) - 5 (5%)
and family history.
Good
4 (4%) - 4 (4%)
The student provides an accurate description of past psychiatric,
substance use, medical, social, and family history.
Fair
0 (0%) - 0 (0%)
Poor

0 (0%) - 3 (3%)
Feedback:
made during interview and review of systems--
Excellent
14 (14%) - 15 (15%)

Good
12 (12%) - 13 (13%)
Fair
11 (11%) - 11 (11%)
Poor
0 (0%) - 10 (10%)

Feedback:
Discussion of diagnostics with results--
Excellent
9 (9%) - 10 (10%)
Good
8 (8%) - 8 (8%)
The student provides an accurate discussion of diagnostics with
results.

Fair
7 (7%) - 7 (7%)
Poor
0 (0%) - 6 (6%)
Feedback:
Diagnosis with three (3) differentials--

Excellent
23 (23%) - 25 (25%)
The student provides an accurate, clear, and complete diagnosis
with three (3) differentials.
Good
20 (20%) - 22 (22%)
differentials.
Fair
18 (18%) - 19 (19%)
Poor

0 (0%) - 17 (17%)
All or most of the discussion is inaccurate or missing. Less than
2 diagnosis.
Feedback:
Comprehensive Psychiatric Evaluation documentation--
Excellent
23 (23%) - 25 (25%)

Good
20 (20%) - 22 (22%)
The response accurately follows the Comprehensive Psychiatric
Evaluation format to document the selected patient case.
Fair
18 (18%) - 19 (19%)
Poor
0 (0%) - 17 (17%)

Feedback:
Presentation style--
Excellent
5 (5%) - 5 (5%)
focused.
Good
4 (4%) - 4 (4%)

Fair
3 (3%) - 3 (3%)
Poor
0 (0%) - 2 (2%)
Presentation style is unclear, unprofessional, and/or unfocused.
Feedback:

Total Points:
100
ASSIGNMENT QUESTION
For this Assignment, you will document information about a
patient that you examined during the last 3 weeks, using the
Comprehensive Psychiatric Evaluation Template provided. You
will then use this note to develop and record a case presentation
for this patient. Be sure to incorporate any feedback you
received on your Week 3 and Week 6 case presentations into
this final presentation for the course.
To Prepare
· Review this week's Learning Resources and consider the
insights they provide. Also review the Kaltura Media Uploader
resource in the left-hand navigation of the classroom for help
creating your self-recorded Kaltura video.
· Select a patient that you examined during the last 3 weeks who
presented with a disorder for which you have not already
conducted an evaluation in Weeks 3 or 6. (For instance, if you
selected a patient with OCD in Week 6, you must choose a
patient with another type of disorder for this week.) Conduct a
Comprehensive Psychiatric Evaluation on this patient using the
template provided in the Learning Resources. There is also a
completed exemplar document in the Learning Resources so that
you can see an example of the types of information a completed
evaluation document should contain.
· Then, based on your evaluation of this patient, develop a video
case presentation that includes chief complaint; history of

present illness; any pertinent past psychiatric, substance
use, medical, social, family history; most recent mental status
exam; and current psychiatric diagnosis including differentials
that were ruled out.
· Include at least five (5) scholarly resources to support your
assessment and diagnostic reasoning.
· Ensure that you have the appropriate lighting and equipment
to record the presentation
Assignment
Record yourself presenting the complex case for your clinical
patient. In your presentation:
· Ensure that you do not include any information that violates
the principles of HIPAA (i.e., don’t use the patient’s name or
any other identifying information).
· Present the full case. Include chief complaint; history of
present illness; any pertinent past psychiatric, substance
use, medical, social, family history; most recent mental status
exam; and current psychiatric diagnosis including differentials
that were ruled out.
· Report normal diagnostic results as the name of the test and
“normal” (rather than specific value). Abnormal results should
be reported as a specific value.
Be succinct in your presentation, and do not exceed 8 minutes.
Address the following:
· Subjective: What details did the patient provide regarding
their personal and medical history? What are their symptoms of
concern? How long have they been experiencing them, and w hat
is the severity? How are their symptoms impacting their
functioning?
· Objective: What observations did you make during the
interview and review of systems?
· Assessment: What were your differential diagnoses? Provide a
minimum of three (3) possible diagnoses. List them from

highest to lowest priority. What was your primary diagnosis,
and why?
· Reflection notes: What would you do differently in a similar
patient evaluation?
Video Presentation of Comprehensive Psychiatric Evaluation
Please work to keep your videos to no more than 8 mins. The
directions for the video presentation are below, please note you
should not read your entire comprehensive submission the key
components list below. Also, work to present the patient not
read from the paper.
· Develop a video case presentation, based on your evaluation
of this patient, that includes chief complaint; history of present
illness; any pertinent past psychiatric, substance use, medical,
social, family history; most recent mental status exam; and
current psychiatric diagnosis, including differentials that were
ruled out.

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