Psychiatry Write a Psychiatric evaluation on a 37-year-old white male with borderline personality disorder. Please see the Rubric below: Grading Rubric for

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Write a Psychiatric evaluation on a 37-year-old white male with borderline personality disorder. Please see the Rubric below:

Grading Rubric for Psychiatric Evaluations and Psychiatric Case Presentations

Category

Unacceptable

Acceptable

Good

Excellent

Demographic Data

0

Does not adequately convey topic. Missing all or most key elements.

1

Includes minimal identifying information. Primary source of information and reliability as well as reason for referral and patient understanding of referral are not included or are unclear.

3

Includes identifying information but leaves out some key elements. Primary source of information and reliability as well as reason for referral and patient understanding of referral are noted.

5

Includes identifying information including initials, age, gender, ethnicity. Primary source of information and reliability as well as reason for referral and patient understanding of referral are clear.

Subjective Data

History of Present Illness (HPI)

0

CC is not recorded. HPI does not reflect a chronological account of symptoms that are sufficiently descriptive to validate Dx per DSM-5 criteria. Pertinent negatives are not included. The longitudinal course of illness is nonexistent.

8

CC is clear. HPI provides an account of symptoms that are descriptive, nonchronological, without context, and do not clearly validate Dx per DSM-5 criteria. Few pertinent negatives are included. A longitudinal course of illness is unclear. Current medications are included.

14

CC is clear, concise and verbatim from pt. HPI is thorough yet concise and provides a chronological account of symptoms with some contextual factors that are sufficiently descriptive (oldcarts) to validate Dx per DSM-5 criteria. Pertinent negatives are included. A longitudinal course of illness is appreciable. Current psychiatric medications and response are included.

20

CC is clear, concise and verbatim from pt. HPI is thorough yet concise and provides a chronological account of symptoms and contextual factors that are sufficiently descriptive (oldcarts) to validate Dx per DSM-5 criteria. All pertinent negatives are included. A longitudinal course of illness is clear. Current psychiatric medications and response are included.

Past Psychiatric History

0

PPH contains no previous treatment Hx including previous Dx, hospitalizations, outpatient treatments, suicide attempts, self-harm, nor is there descriptions of previous medications with detailed trial and response history. Pertinent negatives are not included.

1

PPH contains sparse data regarding previous treatment including previous Dx, hospitalizations, outpatient treatments, suicide attempts, self-harm. Previous medication history is sparse and without detailed trial and response history. Pertinent negatives are unclear.

3

PPH contains most data regarding previous treatment including previous Dx, hospitalizations, outpatient treatments, suicide attempts, self-harm, and previous medications with detailed trial and response history. Pertinent negatives are also included.

5

PPH contains all previous treatment including previous Dx, hospitalizations, outpatient treatments, suicide attempts, self-harm, and previous medications with detailed trial and response history. Pertinent negatives are also included.

Substance Use History

0

Substance use history is not documented. No inclusion of addictive behavioral patterns.

1

Substance use history is documented but data is sparse. Pertinent negatives are unclear. Age of onset, duration, frequency/pattern of use, route of administration, last use, consequences of use are not all included. Not limited to illicit substances. Review of addictive behavioral patterns absent.

3

Complete substance use history is documented. Most pertinent negatives are documented. Age of onset, duration, frequency/pattern of use, route of administration, last use, consequences of use. Not limited to illicit substances. Inclusive of addictive behavioral patterns.

5

Complete substance use history is documented. Pertinent negatives are clear evidenced by appropriate pt. responses ie. “denies”. Age of onset, duration, frequency/pattern of use, route of administration, last use, consequences of use. Not limited to illicit substances. Inclusive of addictive behavioral patterns.

Past Medical History and Review of Systems (ROS)

0

Medical history is incomplete or absent. ROS is not complete or is not free from objective assessment data ie. “lungs clear” “BS present”

1

Medical history includes previous and current medical problems, surgeries, and allergies. ROS may be extraneous or incomplete for the presenting psychiatric problems and is not free from objective assessment data ie. “lungs clear” “BS present”

3

Medical history includes previous and current medical problems, surgeries, and allergies. ROS is germane to the presenting psychiatric problems but is not free from objective assessment data ie. “lungs clear” “BS present”

5

Medical history includes previous and current medical problems, surgeries, and allergies. ROS is germane to the presenting psychiatric problems and is free from objective assessment data ie. “lungs clear” “BS present”.

Family History Psychosocial and Developmental History

0

Family Hx is minimal or nonexistent and does not include identified relational status with current or historical psych illness, treatments, responses, suicides, or self-harm. Dev’t Hx minimally or does not include info regarding family of origin, siblings, birth order, family dynamics, relational patterns and status, educational, employment, abuse, spirituality, legal, military. Dev’t milestones for child & adolescents are not included

3

Family Hx includes some of the identified relational status with current or historical psych illness, treatments, responses, suicides, or self-harm. No indication if biologically related. Dev’t Hx includes minimal info regarding family of origin, siblings, birth order, family dynamics, relational patterns and status, educational, employment, abuse, spirituality, legal, military. Few dev’t milestones for child & adolescents are included

7

Family Hx includes current or historical psych illness without clear identification of relation, but does include treatments, responses, suicides, or self-harm. Dev’t Hx includes most info regarding family of origin, siblings, birth order, family dynamics, relational patterns and status, educational, employment, abuse, spirituality, legal, military. Dev’t milestones for child &

adolescents are included

10

Family Hx includes identified relational status with current or historical psych illness, treatments, responses, suicides, or self-harm. Indication if biologically related. Dev’t Hx includes info regarding family of origin, siblings, birth order, family dynamics, relational patterns and status, educational, employment, abuse, spirituality, legal, military. Dev’t milestones for child & adolescents are included

Objective Data

Mental Status Exam Physical Exam (as appropriate) vital signs, height, weight, labs or other relevant diagnostics.

0

MSE missing most elements.

Physical exam not documented

5

MSE contains all elements as outlined in addendum..

Is in narrative form and effectively and vividly describes the patient’s presentation. Concrete examples of all assessment results are included ie. “able to correctly interpret 2/3 simple proverbs” to validate documentation of “abstract thought intact”.

10

MSE contains all elements as outlined in addendum..

Is in narrative form and effectively and vividly describes the patient’s presentation. Concrete examples of all assessment results are included ie. “able to correctly interpret 2/3 simple proverbs” to validate documentation of “abstract thought intact”.

15

MSE contains all elements as outlined in addendum..

Is in narrative form and effectively and vividly describes the patient’s presentation. Concrete examples of all assessment results are included ie. “able to correctly interpret 2/3 simple proverbs” to validate documentation of “abstract thought intact”.

Assessment

0

Differential is impertinent to S&S or absent. Formulation does not support nor clearly outline thought process of diagnoses. Diagnoses tendered are not supported by criteria in the HPI description or substantiated with the MSE.

3

Differential is impertinent to S&S, formulation appears rudimentary and vague. Diagnoses are made per DSM-5 but are marginally reasonable. Criteria for diagnoses tendered are not explicit in the HPI description or substantiated with the MSE.

7

Differential is pertinent to S&S, formulation contains evidence of critical thought and subject knowledge, and reasonable diagnoses are made per DSM-5. Clearly met criteria for diagnoses tendered are explicit in the HPI description and substantiated with the MSE.

10

Differential is pertinent to S&S, formulation contains evidence of critical thought and subject knowledge, and reasonable diagnoses are made per DSM-5. Clearly met criteria for diagnoses tendered are explicit in the HPI description and substantiated with the MSE.

Plan

0

Treatment plan is presented without sound rationales. There is no evidence of synthesis of information or critical thought.

5

Evidence-based treatment plan is presented with minimal rationales. Rationales reflect the student’s marginal ability to choose treatments based not only on FDA approval or current evidence but also the nuances and unique characteristics of each. Treatment plan is reasonable but lacks comprehensiveness. There is minimal evidence of synthesis of information and critical thought.

10

Evidence-based treatment plan is presented with rationales. Level of detail reflects the student’s moderate ability to choose treatments based not only on FDA approval or current evidence but also the nuances and unique characteristics of each. Treatment plan is holistic and comprehensive. There is some evidence of the student’s synthesis of information and critical thought.

15

Evidence-based treatment plan is presented with detailed rationales. Level of detail reflects the student’s ability to choose treatments based not only on FDA approval or current evidence but also the nuances and unique characteristics of each. Treatment plan is holistic and comprehensive. There is strong evidence of the student’s synthesis of information and critical thought.

Writing, Support, APA

0

The format is not consistent with the example provided in the course. No recent, scholarly, peer- reviewed support of topic. Substantial grammar, spelling, and punctuation errors detracting from the assignment. Writing mechanics include many awkward or unclear passages and informal tone not consistent with formal scholarly work. Substantial errors in APA style based upon the required APA manuals listed on the course syllabi.

1

The format is marginally consistent with the example provided in the course. Limited recent (5-7 years), scholarly, peer- reviewed support of topics. Occasional spelling, grammar, and punctuation errors detracting from the assignment. Writing mechanics include awkward or unclear passages and informal tone not always consistent with formal scholarly work. Occasional errors in APA style based upon the required APA manuals listed on the course syllabi.

3

The format is fairly consistent with the example provided in the course. Clear, recent (5-7 years), scholarly, peer- reviewed support of topics. Minimal grammar, spelling, and punctuation errors. Writing mechanics include minimal awkward or unclear passages but are consistent with formal scholarly work. Minimal errors in APA style manuals listed on the course syllabi.

5

The format is consistent with the example provided in the course. Strong, recent (5-7 years), scholarly, peer- reviewed support of topics. No grammar, spelling, and punctuation errors. Writing mechanics are consistent with formal scholarly work. No errors in APA style based upon the required APA manuals listed on the course syllabi.

1

Addendum

Mental Status Exam Elements- All Borderline Subjects Are Tough Troubled Characters

A- Appearance

Height, build, hair color, style, facial hair, body modifications, facial features, scars, grooming, hygiene, odors, clothing, make-up, impression of general appearance and memorable aspects.

B- Behavior

Attitude

Motor activity

S- Speech

General quality

Fluency

Amount

Rate

Tone

Volume

Prosody

Spontaneity or Latency

A- Affect

Qualities of Affect

Stability

Appropriateness

Range

Intensity

Mood as defined by patient. Usually in quotation marks

T- Thought process

Flow and processing of thought. Examples:

Circumstantiality

Clang associations

Fight of ideas

Perseveration

Thought blocking

T- Thought content

Suicidal ideation (SI), Homicidal ideation (HI), Violent ideation (VI). If + comment on intent, plan, and preparation

Psychotic ideation or perceptual disturbances. Examples:

Delusions or hallucinations

Obsessional thoughts

Compulsions

Ideas of reference

Paranoia (suspiciousness)

Significant themes related to diagnosis

C- Cognitive exam – consider educational attainment when interpreting results.

Alertness

Orientation

Concentration

Memory (long and short term)

Calculation

Fund of knowledge

Abstract reasoning

Insight

Judgment

Physical Exam- Will be completed as appropriate to clinical setting. Physical exam results will vary in content. The instructor should use their discretion when considering the relative weight of this section.

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