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Posted: October 31st, 2023
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.
Review this week's Learning Resources and consider the insights they provide. Also review the Kaltura Media resource in the Classroom Support Center area (accessed via the Help button).
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 by your Preceptor. When you submit your document, you should include the complete Comprehensive Psychiatric Evaluation as a Word document, and the completed assignment signed by your Preceptor. You must submit your document using Turn It In. 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.
Ensure that you have the appropriate lighting and equipment to record the presentation.
Record yourself presenting the complex case for your clinical patient.
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Do not sit and read your written evaluation! The video portion of the assignment is a simulation to demonstrate your ability to succinctly and effectively present a complex case to a colleague for a case consultation. The written portion of this assignment is a simulation for you to demonstrate to the faculty your ability to document the complex case as you would in an electronic medical record. The written portion of the assignment will be used as a guide for faculty to review your video to determine if you are omitting pertinent information or including non-essential information during your case staffing consultation video.
In your presentation:
Dress professionally and present yourself in a professional manner.
Display your photo ID at the start of the video when you introduce yourself.
Ensure that you do not include any information that violates the principles of HIPAA (i.e., don’t use the patient’s name or any other identifying information).
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? Reflect on one social determinant of health according to the HealthyPeople 2030 (you will need to research) as applied to this case in the realm of psychiatry and mental health. As a future advanced provider, what are one health promotion activity and one patient education consideration for this patient for improving health disparities and inequities in the realm of psychiatry and mental health? Demonstrate your critical thinking.
28 year old male patient coming in to the clinic with significant mood swings in the past year . Pt reports periods of feeling very erratic , where he engages in reckless behaviors like driving above speed limit because he only lives once and not sleeping because he does not need it and feels energetic either way . Pt also states periods of depression where he spends days in his room without going out . Will start patient on valproic acid 250 mg twice a day for mood stabilization . Will follow up with patient in 4 weeks .
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Comprehensive Psychiatric Evaluation
Chief Complaint
The chief complaint is mood swings occurring over the past year with alternating periods of manic and depressive symptoms.
History of Present Illness
The patient is a 28-year-old male who presents with a one-year history of mood instability. He reports periods lasting 4-7 days where he feels very erratic and engages in reckless behaviors such as speeding while driving and not sleeping because he feels energetic. During these times, his thought process can be disorganized. He also experiences depressive episodes where he spends days isolated in his room without motivation. These episodes are interfering with his daily functioning.
Past Psychiatric History
No previous psychiatric treatment or hospitalizations.
Medical History
No significant medical issues reported.
Family History
No known family history of mood disorders.
Social History
The patient lives alone and is employed full-time. He reports his symptoms have impacted his work performance at times but he has not missed any days. He is single with no children.
Mental Status Examination
The patient appeared restless during the interview with labile mood and affect shifting rapidly between euphoria and depression. His thought process was disorganized at times.
Diagnostic Impression
Based on the cyclical nature of distinct manic and depressive episodes, the leading diagnosis is:
Bipolar I disorder, current episode manic with mixed features.
Differential diagnoses considered but deemed less likely include:
Schizoaffective disorder (bipolar type)
Borderline personality disorder
Treatment Plan
Initiate valproic acid 250 mg twice daily for mood stabilization
Follow up with provider in 4 weeks to assess treatment response and side effects
Provide patient education on medication adherence, lifestyle modifications, and early warning signs of relapse
Referral to outpatient therapy to help with coping skills and symptom management
In conclusion, this 28-year-old male patient presents with a history and examination findings most consistent with a diagnosis of bipolar I disorder. Close monitoring of his treatment response is warranted given the severity of his symptoms. Addressing any social determinants of health through referrals and patient education may help support his long-term wellness and recovery.
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