Cheap essays, research papers, dissertations.NRNP 6635 Assessing and Diagnosing Patients With Mood Disorders
Sample Answer for NRNP 6635 Assessing and Diagnosing Patients With Mood Disorders Included After Question
Accurately diagnosing depressive disorders can be challenging given their periodic and, at times, cyclic nature. Some of these disorders occur in response to stressors and, depending on the cultural history of the client, may affect their decision to seek treatment. Bipolar disorders can also be difficult to properly diagnose. While clients with a bipolar or related disorder will likely have to contend with the disorder indefinitely, many find that the use of medication and evidence-based treatments have favorable outcomes.
Resources
Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.
WEEKLY RESOURCES
To Prepare:
Review this week’s Learning Resources. Consider the insights they provide about assessing and diagnosing mood disorders.
Download the Comprehensive Psychiatric Evaluation Template, which you will use to complete this Assignment. Also review the Comprehensive Psychiatric Evaluation Exemplar to see an example of a completed evaluation document.
By Day 1 of this week, select a specific video case study to use for this Assignment from the Video Case Selections choices in the Learning Resources. View your assigned video case and review the additional data for the case in the “Case History Reports” document, keeping the requirements of the evaluation template in mind.
Consider what history would be necessary to collect from this patient.
Consider what interview questions you would need to ask this patient.
Identify at least three possible differential diagnoses for the patient.
By Day 7 of Week 3
Complete and submit your Comprehensive Psychiatric Evaluation, including your differential diagnosis and critical-thinking process to formulate a primary diagnosis. Incorporate the following into your responses in the template:
Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life?
Objective: What observations did you make during the psychiatric assessment?
Assessment: Discuss the patient’s mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses with supporting evidence, listed in order from highest priority to lowest priority. Compare the DSM-5-TR diagnostic criteria for each differential diagnosis and explain what DSM-5 criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
Reflection notes: What would you do differently with this client if you could conduct the session over? Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).
submission information
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A Sample Answer For the Assignment: NRNP 6635 Assessing and Diagnosing Patients With Mood Disorders
Title: NRNP 6635 Assessing and Diagnosing Patients With Mood Disorders
Subjective:
CC (chief complaint): “I sometimes forget to take my medications”
HPI: A.T. is a 27-year-old female patient who came to the psychiatric clinic with a history of mood disorder. She reports that she has been missing her doses due to forgetfulness. She has a history of hypertension which she manages with Trandate 100mg twice daily. She denies previous suicidal gestures.
Past Psychiatric History:
General Statement: The patient’s psychiatric history is unremarkable. She was diagnosed with bipolar disorder ever since she was a young girl.
Caregivers (if applicable): The patient’s parents got divorced about 10 years ago, and she has been staying with her mother ever since. She recently got her first child about 2 months ago.
Hospitalizations: No hospitalization history.
Medication trials: The patient has been taking mood stabilizers, but she has not been compliant due to forgetfulness.
Psychotherapy or Previous Psychiatric Diagnosis: Denies any history of psychotherapy for her current or past mental condition.
Substance Current Use and History: The patient claims to have never taken alcohol or smoked cigarettes. She also denies using any other illicit drug of abuse.
Family Psychiatric/Substance Use History: The patient reports that her brother committed suicide through GSW. She also reports that her brother was addicted to methamphetamine.
Psychosocial History: The patient recently got her fast child two months ago. She worked in the community library for 5 years, but currently lives with her mother. The patient’s parents got divorced about 10 years ago, and she has been staying with her mother ever since. She has two sisters who live in a different town. She is a bachelor’s degree graduate, majoring in Literature.
Medical History:
Current Medications: Trandate 100mg PO twice daily for HTN
Allergies: Denies food or environmental allergies.
Reproductive Hx: Heterosexual with the first child 2 months old.
ROS:
GENERAL: The patient is healthy with no fever, headache, dizziness, urination issue, or chest pain.
HEENT: Head: atraumatic. Eyes: No visual changes, blurred vision, use of corrective lenses, or red/itchy eyes. Nose: No congestion, irritations, inflammation, nose bleeding, or sinus problems. Throat & Mouth: No sore throat, bleeding gums, or swallowing difficulties.
SKIN: Denies discoloration, hives, rashes, blisters, lumps, or ulcers.
CARDIOVASCULAR: Denies chest pressure, pain, edema, or palpitations.
RESPIRATORY: No wheezing, sneezing, dyspnea, coughing, or chest congestion.
GASTROINTESTINAL: No abdominal pain, hernia, constipation, diarrhea, or changes in bowel movement.
GENITOURINARY: No changes in urine frequency, urgency, or burning sensation when urination. Report normal vaginal discharge.
NEUROLOGICAL: No headache, changes in vision, loss of consciousness, or dizziness.
MUSCULOSKELETAL: exhibits full ranges of movement in both upper and lower extremities. No joint stiffness or pain.
HEMATOLOGIC: No bleeding problems or prolonged healing of wounds.
LYMPHATICS: No signs of enlarged lymph nodes.
ENDOCRINOLOGIC: Denies polyuria, polyphagia, or polydipsia. No hypothyroidism.
Objective:
Vital Signs: T- 98.9 P- 97 R 22 150/88 Ht 5’5 Wt. 135lbs
Physical exam
HEENT: Head is atraumatic and normocephalic. Pupils are equal in size, round, and equally reactive to light. No erythema or effusion on the tympanic membrane. No discharge or swelling was noted in the ear canals. The neck is supple with anterior cervical lymphadenopathy. The throat is clear with no swelling and exudates. Tonsils are not swollen.
Chest/lungs: Breathing sounds clear to auscultation
Heart: Regular heart rate, with S1 and S2 sounds. S3 absent. No gallop, rales or murmurs.
Abdomen: Non-distended and soft abdomen with no hernia. Normal sounds were noted in all four abdominal quadrants.
Diagnostic results: No tests ordered.
Assessment:
Mental Status Examination: The 27-year-old female patient walked in well-groomed in age-appropriate clothes. The patient maintains eye contact during the interview with appropriate facial expressions. Communicates in a clear language, in a normal tone, and rate of speaking. Her thought process is coherent and logical. She denies delusion, hallucinations, and suicidal ideation. She confirms being forgetful, but her long-term memory is intact. Her insight is absent. The patient displays limited ability to identify the consequences of her actions. Denies suicidal ideation, or a history of suicidal attempts.
Differential Diagnoses:
Bipolar Disorder: According to the DSM-V. bipolar disorder has been defined as a group of mental disorders characterized by extreme fluctuations in the patient’s mood, ability to function, and energy level. There are three main types, but the patient in the provided case study presented with signs of bipolar 1 disorder, which is characterized by manic-depressive episodes (Miskowiak et a., 2018). DSM-V requires the patient to display at least 3 of the following symptoms, racing thoughts, talkativeness, lack of sleep, inflated self-esteem, distracted easily, and psychomotor agitation among others.
Schizophrenia: according to the DSM-V diagnostic criteria, schizophrenia disorder is diagnosed when the patient displays at least two of the following 5 symptoms, incoherent or disorganized speaking, hallucination, delusion, unusual or disorganized movement, and negative symptoms (Tulacı, 2018). The patient in the provided case study does not meet the diagnosis of this disorder.
Major Depressive Disorder (MDD): For a patient to qualify for the diagnosis of MDD, the DSM-V require the presence of at least 5 of the following symptoms within the same two-week period, sleep disturbance, fatigue, worthlessness, weight changes, depressed mood, loss of pleasure and indecisiveness among others (Hasin et al., 2018). The patient in the provided case study presented with a depressed mood, but does not qualify for this diagnosis.
Reflections: The provided patient information is quite substantial to make a diagnosis of bipolar disorder. The clinician did an excellent job collecting information that provides a clear picture of the patient’s symptoms, such as manic and depressive episodes. However, additional information is still missing, to determine the severity of the condition (McIntyre & Calabrese, 2019). The PMHNP also needs to consider the use of screening tools such as mood disorder questionnaires to confirm the primary diagnosis and rule out the differentials (Andersson et al., 2019). Additionally, given that the patient’s condition might affect her life at home, it is necessary to inform the patient mother about her symptoms and how to manage her condition, with her consent. Her mother will help by reminding her to take her medication every time she forgets to promote a positive outcome.
NRNP 6635 Assessing and Diagnosing Patients With Mood Disorders References
Andersson, G., Carlbring, P., Titov, N., & Lindefors, N. (2019). Internet interventions for adults with anxiety and mood disorders: a narrative umbrella review of recent meta-analyses. The Canadian Journal of Psychiatry, 64(7), 465-470. https://doi.org/10.1177/0706743719839381
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. doi:10.1001/jamapsychiatry.2017.4602
McIntyre, R. S., & Calabrese, J. R. (2019). Bipolar depression: the clinical characteristics and unmet needs of a complex disorder. Current medical research and opinion, 35(11), 1993-2005. https://doi.org/10.1080/03007995.2019.1636017
Miskowiak, K. W., Burdick, K. E., Martinez‐Aran, A., Bonnin, C. M., Bowie, C. R., Carvalho, A. F., … & Vieta, E. (2018). Assessing and addressing cognitive impairment in bipolar disorder: the International Society for Bipolar Disorders Targeting Cognition Task Force recommendations for clinicians. Bipolar disorders, 20(3), 184-194. https://doi.org/10.1080/03007995.2019.1636017
Tulacı, Ö. D. (2018). Differences in psychopharmacology of pediatric schizophrenia and adult schizophrenia. Klinik Psikofarmakoloji Bulteni, 28, 338-339. https://www.proquest.com/openview/0d5cf61a680c733184a8abce17abb31b/1?pq-origsite=gscholar&cbl=28708
A Sample Answer 2 For the Assignment: NRNP 6635 Assessing and Diagnosing Patients With Mood Disorders
Title: NRNP 6635 Assessing and Diagnosing Patients With Mood Disorders
Subjective:
CC (chief complaint): Allegations by the patient’s mother that the patient recurrently gets moody this time of the year every year.
HPI: Ms. Julie Houston is a 19-year-old female who came to the psychiatric clinic for assessment following a recommendation from her mother. The patient presented with allegations by her mother that she recurrently gets moody around this time of the year annually. She reports that she is not feeling great and feels down. She admits to not doing so well, especially with her special business program in school. She reports that she comprehends everything but the classes are boring. She feels the teachers are stressing her with projects such as developing a mock company which she is finding difficult to complete. Two of the projects are already long overdue. The patient reports difficulty concentrating. For instance, she can read newspaper headlines and cannot seem to recall them almost immediately, a similar case with her classes. The patient has recently gained weight approximately ten pounds. She is experiencing excessive daytime sleepiness to an extent of sleeping through five of her classes this month. Initially, the patient was social, and easily made a lot of friends with whom she enjoyed their company. She would attend concerts and shows with them and engage in fun activities. However, lately, she finds them annoying, and dull and avoids their company. She currently prefers staying indoors alone which she partly attributes to the cold weather. She expresses her dislike for fall and winter because she cannot engage in activities such as going to the beach and riding in convertibles which she usually does during summer. She associates winter with darkness, and misery as opposed to beauty during summer.
Past Psychiatric History:
General Statement: The patient denies any past psychiatric treatment.
Caregivers (if applicable): Her parents.
Hospitalizations: The patient has never had any psychiatric admissions.
Medication trials: She is not on any medication trials.
Psychotherapy or Previous Psychiatric Diagnosis: The patient has never been diagnosed with any psychiatric disorder or undergone psychotherapeutic interventions.
Substance Current Use and History: The patient denies any history of or current substance abuse or abuse by any member of her family.
Family Psychiatric/Substance Use History: There is no history of any psychiatric condition in her immediate or extended family.
Psychosocial History: The patient grew up in South Carolina and was raised by both her parents. She has three other siblings, two brothers, and one sister. She is currently a full-time student undertaking a business undergraduate program in Boston. She stays with two other female student roommates in off-campus housing. She is unemployed, has never been married, and not dating. She has no history of legal issues or trouble with the authorities.
Medical History: The patient has never been admitted for any medical treatment.
Current Medications: She is not on any prescription medication for any medical condition.
Allergies: She has no known allergies to drugs or drugs.
Reproductive Hx: Her menarche was at fourteen years. She experiences a regular menstrual cycle. Her last menstrual period was 20 days ago. She is not currently gravid. She has never used any contraceptives and has no children.
ROS:
GENERAL: The patient reports no weight loss but a recent weight gain, no fever, and no generalized weakness.
HEENT: There is no vision loss, hearing loss, dysphagia, sore throat, or nasal congestion.
SKIN: The patient denies pruritus, skin rash, or abnormal skin changes.
CARDIOVASCULAR: There are no reported palpitations, easy fatigability, shortness of breath even on exertion, chest pain, or edema.
RESPIRATORY: There is no difficulty in breathing, no chest pain, and no cough.
GASTROINTESTINAL: The patient denies experiencing anorexia, abdominal pain, nausea, vomiting, diarrhea, or constipation.
GENITOURINARY: Patient reports no pain or discomfort on urination, blood in urine, increased frequency, or incontinence.
NEUROLOGICAL: The patient denies headaches, dizziness, numbness, convulsions, weakness, or paralysis.
MUSCULOSKELETAL: There are no myalgias, no joint swelling, pain, or stiffness.
HEMATOLOGIC: The patient denies anemia or excessive bleeding tendency.
LYMPHATICS: There are no swollen lymph nodes or enlarged spleen.
ENDOCRINOLOGIC: The patient denies intolerance to heat or cold, polyuria, polydipsia, polyphagia, or excessive sweating.
Objective:
Physical exam:
Vital signs: Temperature 98.1, PR-78, RR-18, BP 119/74 Ht 5’2” Wt 184lbs
General: The patient is in fair general condition, is not in any form of distress, is well nourished and is well-kempt.
HEENT: The head is normocephalic, pupils are equally reactive to light, the oral cavity is of good hygiene and free of inflammatory processes, ear canals are clear, and the nose is not congested.
Neck: The neck is soft with no masses, no cervical lymphadenopathy, no thyroid swelling, and no distended neck veins.
Chest/Lungs: The chest moves with respiration, and expands symmetrically, vesicular breath sounds are heard on auscultation with good bilateral air entry.
Heart/Peripheral Vascular: The precordium has normal cardiac activity, the apex beat is not displaced, and first and second heart sounds were heard with no added sounds or murmurs.
Abdomen: The abdomen is not distended, not tender, with no abnormal masses, hepatomegaly, and no splenomegaly. Bowel sounds are present.
Genital/Rectal: Findings from a digital rectal examination were normal.
Musculoskeletal: There is no limitation in the range of movement in all joints. No swelling, stiffness, deformity, or tenderness was noted.
Neurological: Cranial nerve assessment is normal. Motor examination of bulk, tone, power, and reflexes are normal. Sensory examination is intact.
Skin: The skin has no lesions or abnormal changes.
Diagnostic results:
Complete blood count revealed values of cell counts that were within normal ranges.
A toxicology screen of blood and urine samples was negative for any drug.
No organisms were isolated from blood cultures.
Random blood sugar showed serum glucose levels that were within normal ranges.
Thyroid function tests were within normal values.
Blood urea, nitrogen, and creatinine were within normal levels.
Liver function tests were non-contributory.
A head CT scan detected no cranial pathology.
Assessment:
Mental Status Examination: The patient is a 19-year-old female who looks appropriate to her stated age. She is well-groomed and appropriately dressed. She is alert and fully cooperates with the examiner. There is no evidence of motor agitation. Her orientation to place, person, and time is intact. Her speech is clear, coherent, and of normal tone, rate, and volume. She has a depressed mood which is congruent with her affect. She exhibits no evidence of flight of ideas or looseness of association. She experiences occasional suicidal thoughts but has no intention of harming herself or others. She has no auditory or visual hallucinations, or delusions. Her immediate and recent memory is impaired evidenced by not remembering newspaper headlines five seconds after reading them and not recalling what she learns from her classes. Her remote and long-term memory is intact. Her concentration is poor. She lacks insight into her condition. Her judgment is good.
Differential Diagnoses:
Bipolar disorder: This is the most likely diagnosis in this patient. This is because the patient exhibits a combination of manic and depressive episodes (Jain et al., 2022). The patient initially experienced a manic episode characterized by elevated mood, increased activity, decreased need for sleep, and increased sociability (Faurholt-Jepsen et al., 2020). During this phase, she could easily make friends and engage in fun activities. The depressive episode that the patient is currently in is characterized by a depressed mood, loss of interest in activities that she initially enjoyed, weight gain, hypersomnia even during classes, reduced concentration, suicidal thoughts, and pessimistic views (Tolentino et al., 2018). The mood disturbance is severe enough to an extent of causing social and functional impairment (Jain et al., 2022). This is evidenced by isolation from her friends whom she initially had cordial relations with. The patient is also having trouble completing her program projects. Bipolar disorder has two incidence peaks of onset the first one being between 15 to 24 years and the second peak occurring between 45 to 54 years (Rowland et al., 2018). The patient is 19 years thus is more predisposed to the first peak. The report by the patient’s mother that the patient gets moody at the same time every year supports the cyclic nature of the condition.
Depressive disorder: This is the other probable diagnosis. The symptoms that the patient is currently presenting with are typical of depressive illness. This is supported by the aforementioned symptoms such as depressed mood, reduced energy, suicidal thoughts, and sleep disturbance. The risk factors that predispose to depressive illness that are present in this patient include age, female gender, previous episode based on information from the patient’s mother and stress that probably stems from the program projects (Park et al., 2019). This diagnosis does not, however, explain the experience of manic symptoms.
Borderline Personality Disorder: The patient may also be having a borderline personality disorder. This disorder usually presents with pervasive affective instability, impulsiveness, suicidal thoughts, and unstable interpersonal relationships that were evident from the history (Kulacaoglu et al., 2018). This diagnosis does not explain the presence of other depressive symptoms such as hypersomnia and depressed mood.
Reflections: The examiner in this case scenario was remarkable in eliciting important information from the patient that guided the formulation of the diagnosis. Involving the patient’s mother provided corroborative information that filled any gaps in the psychiatric assessment. Privacy and confidentiality of the patient were maintained by conducting the assessment in a room with minimal personnel flow. The patient has never been on any psychiatric treatment thus the formulation of the treatment plan will require the provision of adequate information for an informed choice. There should be no coercion in decision-making regarding the treatment approach. The patient is a teenager thus the involvement of the parents in shared decisions may be necessary. Medication trials that will be considered should be beneficial to the patient with minimal risks. The patient lacks insight thus the need for psychoeducation and education on the need for adherence to treatment recommendations. The patient expresses suicidal thoughts thus as an examiner, I would have further explored the suicide risk such as enquiring about previous attempts or intent.
References
Chapman, J., Jamil, R. T., & Fleisher, C. (2022). Borderline Personality Disorder. In StatPearls. StatPearls Publishing.
Faurholt-Jepsen, M., Christensen, E. M., Frost, M., Bardram, J. E., Vinberg, M., & Kessing, L. V. (2020). Hypomania/Mania by DSM-5 definition based on daily smartphone-based patient-reported assessments. Journal of affective disorders, 264, 272–278. https://doi.org/10.1016/j.jad.2020.01.014
Jain, A., & Mitra, P. (2022). Bipolar Affective Disorder. In StatPearls. StatPearls Publishing.
Kulacaoglu, F., & Kose, S. (2018). Borderline personality disorder (BPD): Amid vulnerability, chaos, and awe. Brain Sciences, 8(11), 201. https://doi.org/10.3390/brainsci8110201
Park, L. T., & Zarate, C. A. (2019). Depression in the primary care setting. New England Journal of Medicine, 380(6), 559–568. https://doi.org/10.1056/nejmcp1712493
Rowland, T. A., & Marwaha, S. (2018). Epidemiology and risk factors for bipolar disorder. Therapeutic Advances in Psychopharmacology, 8(9), 251–269. https://doi.org/10.1177/2045125318769235
Tolentino, J. C., & Schmidt, S. L. (2018). DSM-5 criteria and depression severity: Implications for clinical practice. Frontiers in Psychiatry, 9. https://doi.org/10.3389/fpsyt.2018.00450
Accurately diagnosing depressive disorders can be challenging given their periodic and, at times, cyclic nature. Some of these disorders occur in response to stressors and, depending on the cultural history of the client, may affect their decision to seek treatment. Bipolar disorders can also be difficult to properly diagnose. While clients with a bipolar or related disorder will likely have to contend with the disorder indefinitely, many find that the use of medication and evidence-based treatments have favorable outcomes.
To Prepare:
Review this week’s Learning Resources. Consider the insights they provide about assessing and diagnosing mood disorders.
Download the Comprehensive Psychiatric Evaluation Template, which you will use to complete this Assignment. Also review the Comprehensive Psychiatric Evaluation Exemplar to see an example of a completed evaluation document.
By Day 1 of this week, select a specific video case study to use for this Assignment from the Video Case Selections choices in the Learning Resources. View your assigned video case and review the additional data for the case in the “Case History Reports” document, keeping the requirements of the evaluation template in mind.
Consider what history would be necessary to collect from this patient.
Consider what interview questions you would need to ask this patient.
Identify at least three possible differential diagnoses for the patient.
By Day 7 of Week 3
Complete and submit your Comprehensive Psychiatric Evaluation, including your differential diagnosis and critical-thinking process to formulate a primary diagnosis. Incorporate the following into your responses in the template:
NRNP 6635 Assessing and Diagnosing Patients With Mood Disorders
Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differentialdiagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life?
Objective: What observations did you make during the psychiatric assessment?
Assessment: Discuss the patient’s mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses with supporting evidence, listed in order from highest priority to lowest priority. Compare the DSM-5 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.
Reflection notes: What would you do differently with this client if you could conduct the session over? Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).
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NRNP 6635 Assessing and Diagnosing Patients With Mood Disorders Rubric Detail
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Excellent Good Fair Poor
Create 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
• ROS
18 (18%) – 20 (20%)
The response throughly and accurately describes the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis.
16 (16%) – 17 (17%)
The response accurately describes the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis.
14 (14%) – 15 (15%)
The response describes the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis, but is somewhat vague or contains minor innacuracies.
0 (0%) – 13 (13%)
The response provides an incomplete or inaccurate description of the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis. Or, subjective documentation is missing.
In 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. 18 (18%) – 20 (20%)
The response thoroughly and accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are thoroughly and accurately documented.
16 (16%) – 17 (17%)
The response accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are accurately documented.
14 (14%) – 15 (15%)
Documentation of the patient’s physical exam is somewhat vague or contains minor innacuracies. Diagnostic tests and their results are documented but contain minor innacuracies.
0 (0%) – 13 (13%)
The response provides incomplete or inaccurate documentation of the patient’s physical exam. Systems may have been unnecessarily reviewed, or, objective documentation is missing.
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 prior
