Rubric Create documentation in the Comprehensive Psychiatric…

Question Answered step-by-step Rubric Create documentation in the Comprehensive Psychiatric… RubricCreate 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• ROSIn 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.In 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 diagnostic criteria for each differential diagnosis and explain what DSM-5 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.Reflect 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!), 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.).Provide 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).=============================================================================================================Assignment: Assessing and Diagnosing Patients with Mood DisordersSubjective: CC (chief complaint): I am not doing so well this time of the year.HPI: J. H. is a 19-year-old white female who presents for psychiatric evaluation. She complained of not doing well in school, but she verbalized that she felt okay. She is in a particular business program, but she cannot seem to get it done where she is already late on passing two projects. She left the program at school. She stated that after reading the newspaper, she could not remember what she just read. She stated that the teacher is getting to be a bit of a pain. She also reports being unable to concentrate, and she slept through five of her classes this month. She said that she could make friends and later they got dull. She reports that she lost interest quickly and gets mood swings a little bit, and she cannot get over anything. With the weather this time of the year, she stated that it is dark, gray, and miserable—the whole city changes. The patient does not like winter. The patient is not currently on any prescribed psychotropic medication.Past Psychiatric History: General Statement: No previous assessment or treatment for mental health disordersCaregivers (if applicable): N/AHospitalizations: N/A            Medication trials: none          Psychotherapy or Previous Psychiatric Diagnosis: There is no history of psychiatric illness and has never been treated for mental health problems.  Substance Current Use and History: The patient denies any substance use history for her or her familyFamily Psychiatric/Substance Use History: NonePsychosocial History: The patient is single and lives in off-campus housing with two otherfemale roommates. She is a full-time student, not working. She grew up with both parents, two brothers and one sister who lives in South Carolina. J.H. recently started a business in the undergraduate program in Boston, MA. Medical History: noneCurrent Medications: noneAllergies: NKDAReproductive Hx: noneROS: GENERAL: She gained ten pounds.HEENT: no changes in vision, double vision, or jaundice. Ears, Nose Throat: No changes in hearing, congestion, rhinorrhea, or sore throat.SKIN: No changes in skin color. No rash or itching. CARDIOVASCULAR: No chest discomfort or pain, palpitations, or edemaRESPIRATORY: No cough, sputum production, or dyspneaGASTROINTESTINAL: Reports increased appetite. GENITOURINARY: No burning with urination, urgency. Urine color is yellow and clear.NEUROLOGICAL: Alert and oriented. No headache, seizure paralysis, numbness or tingling in extremities. MUSCULOSKELETAL: able to move all extremities. No back pain, joint pain or stiffness.HEMATOLOGIC: No bleeding or anemia problems.          LYMPHATICS: No enlarged nodes noted.ENDOCRINOLOGIC: No sweating, heat, or cold intolerance. No polydipsia or polyuria.Objective:Vital Signs: T-98.1 P-78 R-18, B/P 119/74, Ht. 5’2″ Wt. 184lbsPhysical exam: N/ADiagnostic results: N/AAssessment:Mental Status Examination: J.H. has dressed casually appropriately for the weather. She is alert and oriented x4. Her memory is intact in the assessment. She is cooperative but seems to be distant during the examination. Her speech is clear and coherent, but she speaks in slow and reluctantly answers questions. The mood is depressed and affects flat. Her insight and judgment are fair. Differential Diagnoses: Seasonal Affective Disorder (SAD): Also called the “winter blues.” A form of cyclic mood disorder that manifests as winter depression. SAD has anecdotally been described as a hypocortisolemic condition (Agustini et al., 2019). Seasonal patterns to their mood disorders tend to experience depressive episodes during a particular season, most commonly winter. The design has become known as seasonal affective disorder (SAD), although this term is not using in DSM-5 (Sadock et al., 2015). SAD is a kind of depression that is not a separate disorder but characterized by its recurrent seasonal pattern, with symptoms lasting about 4 – 5 months per year. The patient reports that her mood where symptoms follow a seasonal pattern. In this case, the patient’s mood is affected, especially in the wintertime. Bipolar disorder: A mental disorder causes mood fluctuation, energy, activity levels, concentration, and the ability to conduct day-to-day tasks. There are three types of bipolar disorder. All three types involve apparent h in mood swing, energy, and activity which. These moods range from significantly elevated irritable or energized behavior periods, manic episodes to very depressed and sad or hopeless periods and depressive episodes. Minor mood swing manic periods are hypomanic episodes (National Institute of Mental Health (NIH), 2020). Bipolar I Disorder is as manic episodes that last at least one week or when manic symptoms are uncontrol that hospital care is necessary. The patient stated that my mother said that she gets moody this time of the year every year.On the other hand, depressive episodes happen as well, usually lasting at least two weeks. The patient admitted that her mood is up and down this time of the year. The patient can have exceptionally low moods; like with significant depression, bipolar sufferers who have depressive episodes can feel down on themselves and have energy and motivation. Major Depressive disorder: The expresses depressed or irritable mood for most of the day, decreased interest in previously enjoyable activities, weight loss or weight gain unintentional, insomnia or hypersomnia, physical agitation, or slowness, less of energy or fatigue, feelings of worthlessness, or a diminished ability to concentrate (Oyama, & Piotrowski, 2021). The patient said she slept through five of the classes one month. Reflections: There are different mood disorders related to each other. I have learned the mood disorder, which I can recognize. I have also known other mood disorders can affect people’s life. A precise diagnosis is necessary; it is essential to study and identify the factors and stressors (Sadock et al., 2015). The ethical and legal aspects should have to be carefully measured during the interview of the patient. The decision for the patient recommends seeing treatment and see individual therapy. To chemical, balance the patient needs to understand ant- psychotherapy medications regimen is necessary under the patient’s consent. It is vital to ask about to help determine if thoughts are psychotic or suicidal thoughts to ensure to safety of the patient. References Agustini, B., Bocharova, M., Walker, A. J., Berk, M., Young, A. H., & Juruena, M. F. (2019). Has the sunset for seasonal affective disorder and HPA axis studies? A systematic review and future prospects. Journal of Affective Disorders, 256, 584-593. https://doi-org.ezp.waldenulibrary.org/10.1016/j.jad.2019.06.060National Institute of Mental Health (NIH). (2020). Bipolar disorder. https://www.nimh.nih.gov/health/topics/bipolar-disorder/index.shtmlOyama, O., PhD, & Piotrowski, N. A., PhD. (2021). Depression. Magill’s Medical Guide (Online Edition).Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan & Sadock’s synopsis of psychiatry (11th ed.). Wolters Kluwer.Please revise underline parts and rest of the part proofreading. thank you.    Health Science Science Nursing NRNP 6635 Share QuestionEmailCopy link Comments (0)