What observations did you make during the interview and review of systems?

HISTORY: Ms. Okonofua is a 55-year-old woman. Her chief complaint is, “I have been having

difficulty sleeping and anxiety. These has been going on for years. My anxiety and jitteriness get

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worse when I drink caffeine. I usually don’t sleep for more than 5 hours. I cannot stay asleep. There

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are times that I will not sleep for 3 days and I will be very irritable, unable to concentrate or function

the next day. “.

Anxiety Symptoms:

Ms. Okonofua exhibits symptoms of anxiety. Her anxiety symptoms have been present for

years.

Ms. Okonofua describes the following anxiety symptoms:

*Chest pain or discomfort when under stress.

*Diarrhea

*Increase in Heart Rate

*Sensations of muscular tension

Insomina symptoms

*Sleep disturbance, she has difficulty staying asleep. she has difficulty falling asleep.

*Trembling or shaking

*Excessive worrying

Ms. Okonofua’s symptoms are occurring daily. She reports previous episodes of anxiety

symptoms.

Severity is estimated to be medium based on Ms. Okonofua’s risk of morbidity without

treatment and her description of interference with functioning.

Cardiovascular:

*Hypertension

Eyes:

*Corrective Lenses are used: (Glasses)

Review of all other systems reviewed were negative.

PAST PSYCHIATRIC HISTORY:

Okonofua, Deborah

9/30/1964DOB:

6/9/2020

ID:

page 2 of 5

1000010715483

Complete Evaluation: Continued

medicaid ID:

Room No.

Psychiatric Hospitalization:

Ms. Okonofua has never been psychiatrically hospitalized.

Outpatient Treatment:

Has never received outpatient mental health treatment.

Suicidal/Self Injurious:

Ms. Okonofua has no history of suicidal or self injurious behavior.

Psychotropic Medication History: lexapro (caused weight gain), ambien, benadryl

Prior Psychiatric Disorder:

She has a history of anxiety symptoms.

SOCIAL/DEVELOPMENTAL HISTORY:

Ms. Okonofua is a 55 year old woman. Born and raised in Nigeria, migrated to USA years ago.

Married, has 4 children (1 set of twins), a nurse practitioner.

Abuse/Neglect:

There is no known history of physical, sexual or emotional abuse.

There is no known history of physical, medical, or emotional neglect.

Criminal Justice History:

Ms. Okonofua has never been arrested or incarcerated, has no history of violence, and is

not currently under any kind of court supervision.

Coping Strengths:

Spiritual:

*Religious Beliefs are a Strength

*Spiritual Beliefs are a Strength. “Pastor’s wife”.

Criminal Justice History:

Ms. Okonofua has never been arrested or incarcerated, has no history of violence, and is

not currently under any kind of court supervision.

Substance Abuse:

Ms. Okonofua denies any history of substance abuse.

FAMILY HISTORY:

Mother known to have anxiety.

Ms. Okonofua’s family psychiatric history is otherwise negative. There is no other history of

psychiatric disorders, psychiatric treatment or hospitalization, suicidal behaviors or substance

abuse in closely related family members.

Okonofua, Deborah

9/30/1964DOB:

Assignment 2: Comprehensive Psychiatric Evaluation and Patient Case Presentation

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.

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. All psychiatric evaluations must be signed, and each page must be initialed by your Preceptor. When you submit your document, you should include the complete Comprehensive Psychiatric Evaluation as a Word document, as well as a PDF/images of each page that is initialed and signed by your Preceptor. You must submit your document using SafeAssign. Please Note: Electronic signatures are not accepted. If both files are not received by the due date, Faculty will deduct points per the Walden Late Policies.

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.

Assignment

Record yourself presenting the complex case for your clinical patient. In your presentation:

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 what 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?

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