PRAC 6635 Week 7 Assignment 2 – Step-by-Step Guide

The first step before starting to write the PRAC 6635 Week 7 Assignment 2 Comprehensive Psychiatric Evaluation and Patient Case Presentation, it is essential to understand the requirements of the assignment. The first step is to read the assignment prompt carefully to identify the topic, the length and format requirements. You should go through the rubric provided so that you can understand what is needed to score the maximum points for each part of the assignment. It is also important to identify the audience of the paper and its purpose so that it can help you determine the tone and style to use throughout. You can then create a timeline to help you complete each stage of the paper, such as conducting research, writing the paper, and revising it to avoid last-minute stress before the deadline. After identifying the formatting style to be applied to the paper, such as APA, you should review its use, such as writing citations and referencing the resources used. You should also review how to format the title page and the headings in the paper.

How to Research and Prepare for PRAC 6635 Week 7 Assignment 2

The next step in preparing for your paper is to conduct research and identify the best sources to use to support your arguments. Identify the list of keywords from your topic using different combinations. The first step is to visit the university library and search through its database using the important keywords related to your topic. You can also find books, peer-reviewed articles, and credible sources for your topic from PubMed, JSTOR, ScienceDirect, SpringerLink, and Google Scholar. Ensure that you select the references that have been published in the last words and go through each to check for credibility. 

Ensure that you obtain the references in the required format, for example, in APA, so that you can save time when creating the final reference list. You can also group the references according to their themes that align with the outline of the paper. Go through each reference for its content and summarize the key concepts, arguments and findings for each source. You can write down your reflections on how each reference connects to the topic you are researching about. After the above steps, you can develop a strong thesis that is clear, concise and arguable. Next you should create a detailed outline of the paper so that it can help you to create headings and subheadings to be used in the paper. Ensure that you plan what point will go into each paragraph.

How to Write the Introduction for PRAC 6635 Week 7 Assignment 2

The introduction of the paper is the most crucial part as it helps to provide the context of your work, and will determine if the reader will be interested to read through to the end. You should start with a hook, which will help capture the reader’s attention. You should contextualize the topic by offering the reader a concise overview of the topic you are writing about so that they may understand its importance. You should state what you aim to achieve with the paper. The last part of the introduction should be your thesis statement, which provides the main argument of the paper.

How to Write the Body for PRAC 6635 Week 7 Assignment 2

The body of the paper helps you to present your arguments and evidence to support your claims. You can use headings and subheadings developed in the paper’s outline to guide you on how to organize the body. Start each paragraph with a topic sentence to help the reader know what point you will be discussing in that paragraph. Support your claims using the evidence conducted from the research, ensure that you cite each source properly using in-text citations. You should analyze the evidence presented and explain its significance and how it connects to the thesis statement. You should maintain a logical flow between each paragraph by using transition words and a flow of ideas.

How to Write the In-text Citations for PRAC 6635 Week 7 Assignment 2

In-text citations help the reader to give credit to the authors of the references they have used in their works. All ideas that have been borrowed from references, any statistics and direct quotes must be referenced properly. The name and date of publication of the paper should be included when writing an in-text citation. For example, in APA, after stating the information, you can put an in-text citation after the end of the sentence, such as (Smith, 2021). If you are quoting directly from a source, include the page number in the citation, for example (Smith, 2021, p. 15). Remember to also include a corresponding reference list at the end of your paper that provides full details of each source cited in your text. An example paragraph highlighting the use of in-text citations is as below:

The integration of technology in nursing practice has significantly transformed patient care and improved health outcomes. According to Smith (2021), the use of electronic health records (EHRs) has streamlined communication among healthcare providers, allowing for more coordinated and efficient care delivery. Furthermore, Johnson and Brown (2020) highlight that telehealth services have expanded access to care, particularly for patients in rural areas, thereby reducing barriers to treatment.

How to Write the Conclusion for PRAC 6635 Week 7 Assignment 2

When writing the conclusion of the paper, start by restarting your thesis, which helps remind the reader what your paper is about. Summarize the key points of the paper, by restating them. Discuss the implications of your findings and your arguments. End with a call to action that leaves a lasting impact on the reader or recommendations.

How to Format the Reference List for PRAC 6635 Week 7 Assignment 2

The reference helps provide the reader with the complete details of the sources you cited in the paper. The reference list should start with the title “References” on a new page. It should be aligned center and bolded, in sentence sentence care. The references should be organized in an ascending order alphabetically and each should have a hanging indent. If a source has no author, it should be alphabetized by the title of the work, ignoring any initial articles such as “A,” “An,” or “The.” If you have multiple works by the same author, list them in chronological order, starting with the earliest publication. 

Each reference entry should include specific elements depending on the type of source. For books, include the author’s last name, first initial, publication year in parentheses, the title of the book in italics, the edition (if applicable), and the publisher’s name. For journal articles, include the author’s last name, first initial, publication year in parentheses, the title of the article (not italicized), the title of the journal in italics, the volume number in italics, the issue number in parentheses (if applicable), and the page range of the article. For online sources, include the DOI (Digital Object Identifier) or the URL at the end of the reference. An example reference list is as follows:

References

Johnson, L. M., & Brown, R. T. (2020). The role of telehealth in improving patient outcomes. Journal of Nursing Care Quality, 35(2), 123-130. https://doi.org/10.1097/NCQ.0000000000000456

Smith, J. A. (2021). The impact of technology on nursing practice. Health Press.

An Example PRAC 6635 Week 7 Assignment 2 Follows:

NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template

CC (chief complaint): “I have been feeling persistently sad and hopeless, with no interest in my usual activities, for the past six months. I am also struggling with fatigue, difficulty sleeping, and a significant decrease in appetite.”

HPI: C.M., a 35-year-old male, presents with complaints of persistent sadness, lack of interest in daily activities, and fatigue for the past six months. He also reports difficulty sleeping, a significant decrease in appetite, and unintentional weight loss of about 10 pounds. C.M. describes feelings of worthlessness and guilt, particularly about his inability to function effectively at work. He also mentions having difficulty concentrating and making decisions. These symptoms have progressively worsened, leading him to seek help. C.M. denies any suicidal ideation but expresses a sense of hopelessness about the future. He has no history of manic or hypomanic episodes.

Past Psychiatric History:

  • General Statement: C.M. has a history of major depressive disorder, diagnosed five years ago. He has experienced several episodes since the initial diagnosis, with periods of partial remission. His symptoms have typically included depressed mood, anhedonia, and sleep disturbances.
  • ·       Caregivers (if applicable): C.M. currently lives alone but has a supportive network of friends and family. His sister, J.M., is his primary caregiver and often assists with his medical appointments and daily tasks when his symptoms are severe.
  • ·       Hospitalizations: C.M. has been hospitalized twice for psychiatric reasons. His first hospitalization occurred three years ago following a severe depressive episode with suicidal ideation. The second hospitalization was two years ago after a similar episode. Both hospitalizations lasted approximately one week, during which he received intensive inpatient care and medication adjustments.
  • Medication trials: C.M. has been prescribed several antidepressants over the years, including selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs). He has also tried atypical antipsychotics as an adjunct therapy. C.M. reports partial relief with SSRIs, but he experienced intolerable side effects with SNRIs, leading to discontinuation. He is currently taking sertraline 100 mg daily, which has provided some symptom relief but not complete remission.
  • Psychotherapy or Previous Psychiatric Diagnosis: C.M. has engaged in cognitive-behavioral therapy (CBT) intermittently over the past five years. He found CBT helpful in managing his symptoms and developing coping strategies, though he sometimes struggles with adherence to regular sessions. In addition to his diagnosis of major depressive disorder, C.M. was diagnosed with generalized anxiety disorder two years ago, for which he receives concurrent treatment.

Substance Current Use and History: C.M. reports occasional use of alcohol, typically consuming one to two drinks per week. He denies any history of heavy alcohol use or binge drinking. C.M. also denies the use of tobacco, illicit drugs, or misuse of prescription medications. He has never undergone substance abuse treatment or counseling.

Family Psychiatric/Substance Use History: C.M.’s family psychiatric history includes his mother, who was diagnosed with major depressive disorder and generalized anxiety disorder. She has been on medication for many years and has had several episodes of severe depression requiring hospitalization. C.M.’s father has a history of alcohol use disorder but has been in recovery for the past ten years. There are no other known psychiatric or substance use disorders in his immediate family.

Psychosocial History: C.M. was born and raised in a middle-class family and has one sibling, a sister, J.M. He had a stable and supportive upbringing, though he recalls his mother struggling with depression during his childhood. C.M. completed high school and earned a bachelor’s degree in business administration. He has been employed as a financial analyst for the past ten years. Although he finds his job stressful at times, he generally enjoys his work. C.M. has never been married and has no children. He has a close group of friends and maintains good relationships with his family members. He is physically active, enjoys running, and participates in local community events. However, due to his current depressive symptoms, he has withdrawn from many of his usual activities and social engagements.

Medical History:

  • Current Medications: C.M. is currently taking sertraline 100 mg daily for major depressive disorder and generalized anxiety disorder. He also takes lorazepam 1 mg as needed for acute anxiety, which he uses sparingly, approximately once or twice a month.
  • Allergies: C.M. has no known drug allergies. He reports mild seasonal allergies, for which he occasionally takes over-the-counter antihistamines.
  • Reproductive Hx: C.M. has never been married and has no children. He has no history of sexually transmitted infections or reproductive health issues. He is heterosexual and reports being sexually active, but he has not been in a committed relationship for the past year. He practices safe sex consistently.

ROS:

  • GENERAL: Reports unintentional weight loss of about 10 pounds over the past six months, fatigue, and difficulty sleeping. Denies fever, chills, or night sweats.
  • HEENT: Denies headaches, visual changes, hearing loss, nasal congestion, sore throat, or difficulty swallowing.
  • SKIN: Denies rashes, itching, or skin texture or color changes. No history of skin lesions.
  • CARDIOVASCULAR: Denies chest pain, palpitations, or shortness of breath on exertion. No history of hypertension or heart disease.
  • RESPIRATORY: Denies cough, wheezing, shortness of breath, or history of respiratory infections.
  • GASTROINTESTINAL: Reports a significant decrease in appetite but denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits.
  • GENITOURINARY: Denies dysuria, frequency, urgency, hematuria, or any genitourinary issues. No history of sexually transmitted infections.
  • NEUROLOGICAL: Denies headaches, dizziness, fainting, seizures, or weakness. No history of neurological disorders.
  • MUSCULOSKELETAL: Denies joint pain, muscle pain, stiffness, or swelling. Maintains regular physical activity through running.
  • HEMATOLOGIC: Denies easy bruising, bleeding tendencies, or history of anemia.
  • LYMPHATICS: Denies swollen lymph nodes or history of lymphatic disorders.
  • ENDOCRINOLOGIC: Denies excessive thirst, frequent urination, heat or cold intolerance, or history of thyroid or endocrine disorders.

Physical exam:

GENERAL: The patient appears well-nourished but slightly underweight, with no acute distress. He is alert and oriented to person, place, and time.

VITAL SIGNS:

Blood Pressure: 123/72 mmHg
Heart Rate: 79 beats per minute
Respiratory Rate: 16 breaths per minute
Temperature: 98.6°F
Oxygen Saturation: 98% on room air

HEENT:

Head: Normocephalic, atraumatic.
Eyes: Pupils equal, round, and reactive to light and accommodation. Sclerae and conjunctivae are clear. No icterus.
Ears: External auditory canals are clear, tympanic membranes intact.
Nose: Nasal mucosa is normal, no discharge.
Throat: Oropharynx is clear, no erythema or exudate.

NECK: Supple, no lymphadenopathy or thyromegaly. Trachea is midline.

CARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs, or gallops. Peripheral pulses are 2+ and symmetric.

RESPIRATORY: Clear to auscultation bilaterally, no wheezes, rales, or rhonchi. No use of accessory muscles for breathing.

GASTROINTESTINAL: Abdomen is soft, non-tender, and non-distended. Bowel sounds are present in all quadrants. No hepatosplenomegaly or masses.

GENITOURINARY: No inguinal hernias, no suprapubic tenderness. External genitalia normal, no lesions.

NEUROLOGICAL: Cranial nerves II-XII are intact. Motor strength is 5/5 in all extremities. Sensation is intact to light touch, pinprick, and vibration. Deep tendon reflexes are 2+ and symmetric. Gait is normal.

MUSCULOSKELETAL: Full range of motion in all major joints. No joint swelling, deformities, or tenderness. No muscle atrophy.

SKIN: No rashes, lesions, or abnormal pigmentation. Skin is warm and dry to touch.

LYMPHATICS: No cervical, axillary, or inguinal lymphadenopathy.

ENDOCRINE: No signs of thyroid enlargement or nodules. No tremors or other signs of endocrine dysfunction.

Diagnostic results:

1. Complete Blood Count (CBC):

  • White Blood Cells (WBC): 6.2 x 10^3/µL (normal range: 4.0-10.0 x 10^3/µL)
  • Hemoglobin (Hb): 14.1 g/dL (normal range: 13.5-17.5 g/dL for males)
  • Hematocrit (Hct): 42.3% (normal range: 38.8-50.0% for males)
  • Platelets: 250 x 10^3/µL (normal range: 150-450 x 10^3/µL)

Interpretation: The CBC results are within normal limits, indicating no signs of infection, anemia, or thrombocytopenia.

2. Basic Metabolic Panel (BMP):

  • Sodium (Na): 139 mEq/L (normal range: 135-145 mEq/L)
  • Potassium (K): 4.2 mEq/L (normal range: 3.5-5.0 mEq/L)
  • Chloride (Cl): 102 mEq/L (normal range: 98-107 mEq/L)
  • Bicarbonate (HCO3): 25 mEq/L (normal range: 22-29 mEq/L)
  • Blood Urea Nitrogen (BUN): 15 mg/dL (normal range: 7-20 mg/dL)
  • Creatinine: 0.9 mg/dL (normal range: 0.6-1.2 mg/dL)
  • Glucose: 90 mg/dL (normal range: 70-99 mg/dL)

Interpretation: The BMP results are within normal limits, indicating proper kidney function and electrolyte balance, as well as normal blood glucose levels.

3. Thyroid Function Tests (TFTs):

  • Thyroid-Stimulating Hormone (TSH): 2.1 µIU/mL (normal range: 0.4-4.0 µIU/mL)
  • Free T4: 1.2 ng/dL (normal range: 0.8-2.0 ng/dL)

Interpretation: The thyroid function tests are within normal limits, indicating that thyroid function is normal and not contributing to the patient’s depressive symptoms.

Assessment

Mental Status Examination:

C.M. is a 35-year-old male who appears well-nourished and slightly underweight. He is neatly dressed and maintains good personal hygiene. During the interview, he is cooperative and establishes good eye contact. His speech is normal in rate, volume, and articulation, and he communicates effectively. However, his mood is reported as “sad,” and his affect is notably restricted, reflecting a depressed and anxious demeanor. 

C.M. is oriented to person, place, and time. His thought processes are coherent and goal-directed, without evidence of formal thought disorder. There are no signs of hallucinations or delusions, and he denies any perceptual disturbances. Despite the coherence of his thoughts, C.M. expresses pervasive feelings of worthlessness and guilt, particularly concerning his perceived failures at work and in his personal life. He articulates a sense of hopelessness about the future but denies any current suicidal ideation or intent. 

His cognitive functions appear intact; he performs well on tasks requiring attention and concentration, though he notes subjective difficulties with these areas in his daily life. Memory for recent and remote events is intact, and he demonstrates an adequate fund of knowledge. Insight into his condition is good, as he recognizes the symptoms of his depression and anxiety and understands the need for ongoing treatment. His judgment is also deemed intact, as evidenced by his decision to seek professional help and his compliance with prescribed treatment plans.

Differential Diagnoses:

  1. Major Depressive Disorder (MDD):

C.M. presents with a six-month history of persistent sadness, lack of interest in daily activities, fatigue, difficulty sleeping, decreased appetite, and significant weight loss. These symptoms meet the DSM-5 criteria for major depressive disorder, which requires the presence of at least five of the nine specified symptoms over a two-week period, including either depressed mood or anhedonia (Greenberg et al., 2021). C.M. also reports feelings of worthlessness and guilt, difficulty concentrating, and a sense of hopelessness. The absence of manic or hypomanic episodes rules out bipolar disorder, supporting the diagnosis of MDD.

Pertinent Positives:

  • Persistent depressed mood
  • Anhedonia
  • Fatigue
  • Insomnia
  • Significant weight loss
  • Feelings of worthlessness and guilt
  • Difficulty concentrating
  • Hopelessness

Pertinent Negatives:

  • No history of manic or hypomanic episodes
  • No psychotic symptoms
  • No substance abuse contributing to the symptoms

The presence of the key symptoms of MDD, without any history of mania or hypomania, strongly supports this diagnosis. The patient’s history of previous depressive episodes and hospitalizations also aligns with recurrent MDD. The significant impact on daily functioning and the chronic nature of his symptoms further justify this primary diagnostic impression.

  1. Generalized Anxiety Disorder (GAD):

C.M. has a concurrent diagnosis of generalized anxiety disorder, which was made two years ago. GAD is characterized by excessive anxiety and worry occurring more days than not for at least six months, which is difficult to control and associated with symptoms such as restlessness, fatigue, difficulty concentrating, irritability, muscle tension, and sleep disturbances (Tran, 2020). C.M. reports ongoing anxiety, difficulty sleeping, and concentration issues, which are consistent with GAD.

Pertinent Positives:

  • Chronic worry and anxiety
  • Difficulty controlling worry
  • Sleep disturbances
  • Difficulty concentrating

Pertinent Negatives:

  • No panic attacks
  • No specific phobias
  • No obsessive-compulsive behaviors

While GAD can coexist with MDD, the primary concern in C.M.’s case is the depressive symptoms, which are more prominent and debilitating at present. The chronic anxiety does contribute to his overall symptomatology but is secondary to the primary diagnosis of MDD in terms of impact on his functioning.

  1. Persistent Depressive Disorder

Persistent depressive disorder involves chronic depression lasting for at least two years. Symptoms are typically less severe than MDD but are more persistent (Schramm et al., 2020). C.M. has a history of long-standing depressive symptoms with partial remissions, which may suggest dysthymia. The primary features include low mood, low self-esteem, and fatigue.

Pertinent Positives:

  • Long-standing depressive symptoms
  • Chronic low mood
  • Fatigue

Pertinent Negatives:

  • Episodes of more severe depression (consistent with MDD)
  • Significant weight loss and anhedonia (more aligned with MDD)
  • No clear delineation of a two-year period with persistent milder symptoms without severe episodes

While C.M.’s chronic depressive history could suggest dysthymia, the presence of severe episodes and significant functional impairment points more strongly towards recurrent major depressive disorder. Dysthymia is less likely, given the severity and episodic nature of his symptoms.

Primary Diagnostic Impression:

The primary diagnostic impression for C.M. is Major Depressive Disorder, Recurrent. This diagnosis is supported by the DSM-5 criteria and the patient’s clinical presentation, including significant depressive symptoms, episodic history, and impact on daily functioning. The recurrent nature of his depressive episodes, as evidenced by previous hospitalizations and treatment history, further solidifies this diagnosis. Literature supports the comorbidity of MDD and GAD, which can coexist and exacerbate each other’s symptoms (Greenberg et al., 2021). In C.M.’s case, while GAD is present, the depressive symptoms are more prominent and debilitating, justifying MDD as the primary diagnosis.

Reflections:

In a similar patient evaluation, I would prioritize a more comprehensive exploration of social determinants of health that may impact the patient’s mental health. This includes obtaining a detailed history of the patient’s social environment, work conditions, economic stability, access to healthcare, and social support systems. Understanding these factors can provide insight into potential stressors that may exacerbate mental health conditions. Additionally, I would incorporate more structured diagnostic tools and rating scales, such as the Patient Health Questionnaire-9 (PHQ-9) for depression and the Generalized Anxiety Disorder 7 (GAD-7) scale, to quantitatively assess the severity of symptoms and monitor treatment progress over time.

Healthy People 2030

One key social determinant of health, according to Healthy People 2030, is access to healthcare. Access to healthcare involves the ability to obtain necessary medical services, including mental health care when needed. In the realm of psychiatry and mental health, limited access to mental health services can significantly affect patient outcomes. Factors such as lack of insurance coverage, high treatment costs, transportation barriers, and the availability of mental health professionals can impede access to care (Jackson et al., 2021). In C.M.’s case, ensuring he has adequate access to mental health services is crucial. This involves evaluating whether he has insurance coverage for mental health care, the availability of nearby mental health providers, and any logistical barriers that might prevent him from attending therapy sessions or follow-up appointments. By addressing these factors, we can help reduce the burden of mental health conditions and improve overall outcomes.

Health Promotion Activity

As a future advanced provider, one health promotion activity I would implement for C.M. is the integration of a regular exercise program into his treatment plan. Research has shown that physical activity can have significant benefits for mental health, including reducing symptoms of depression and anxiety (Fossati et al., 2021). Encouraging C.M. to engage in regular physical activity, such as running, which he already enjoys, can enhance his mood, increase energy levels, and provide a healthy coping mechanism for stress.

Patient Education Consideration:

One important patient education consideration for improving health disparities and inequities in the realm of psychiatry and mental health is educating C.M. about the importance of adhering to his treatment plan, including medication and psychotherapy. This involves explaining the benefits of consistent medication use, even when symptoms improve, and the role of psychotherapy in developing coping strategies and addressing underlying issues. Additionally, providing information on local resources, support groups, and community programs can help C.M. feel more supported and connected, which can be particularly beneficial for individuals experiencing depression and anxiety.

PRECEPTOR VERIFICATION:

I confirm the patient used for this assignment is a patient that was seen and managed by the student at their Meditrek approved clinical site during this quarter course of learning.

Preceptor signature: ________________________________________________________

Date: ________________________

PRAC 6635 Week 7 Assignment 2 References

Fossati, C., Torre, G., Vasta, S., Giombini, A., Quaranta, F., Papalia, R., & Pigozzi, F. (2021). Physical exercise and mental health: The routes of a reciprocal relation. International Journal of Environmental Research and Public Health, 18(23), 12364. https://doi.org/10.3390/ijerph182312364

Greenberg, P. E., Fournier, A. A., Sisitsky, T., Simes, M., Berman, R., Koenigsberg, S. H., & Kessler, R. C. (2021). The economic burden of adults with major depressive disorder in the United States (2010 and 2018). Pharmacoeconomics, 39(6), 653-665. https://doi.org/10.1007/s40273-021-01019-4

Jackson, D. N., Trivedi, N., & Baur, C. (2021). Re-prioritizing digital health and health literacy in healthy people 2030 to affect health equity. Health Communication, 36(10), 1155-1162. https://doi.org/10.1080/10410236.2020.1748828

Schramm, E., Klein, D. N., Elsaesser, M., Furukawa, T. A., & Domschke, K. (2020). Review of dysthymia and persistent depressive disorder: history, correlates, and clinical implications. The Lancet Psychiatry, 7(9), 801-812. https://doi.org/10.1016/S2215-0366(20)30099-7

Tran, A. G. (2020). Using the GAD-7 and GAD-2 generalized anxiety disorder screeners with student-athletes: empirical and clinical perspectives. The Sport Psychologist, 34(4), 300–309. https://doi.org/10.1123/tsp.2020-0028

Are you finding it easy creating those patient logs? Another week of writing is coming up next in NRNP 6635 week 9 assignment, which offers another case presentation, for which you will prepare a comprehensive psychiatric evaluation.

Frequently Asked Questions (FAQs)

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