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Comprehensive Psychiatric Evaluation and Patient Case Presentation

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Assignment 2: Comprehensive Psychiatric Evaluation and Patient Case Presentation Photo Credit: PexelsFor 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. To PrepareReview this week’s Learning Resources and consider the insights they provide. Also review the Kaltura Media Uploader resource in the left-hand navigation of the classroom for help creating your self-recorded Kaltura video.
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.
Ensure that you have the appropriate lighting and equipment to record the presentation
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.
Patient Case:
Patient A.M is a 18-year-old Hispanic female DX with F31.9 Unspecified bipolar and related disorder, F43.10 Posttraumatic stress disorder, F10.20 Alcohol use disorder, Severe, F11.20 Opioid use disorder, Moderate, F12.20 Cannabis use disorder, Severe. sHe is alert and orientated, appears in good health, is dressed appropriately for the occasion, and is a good historian. Pt has NKA, reports no issues with eating, hydration, or sleep. she endorsed anxiety and depression. Denied SI/HI or AVH currently. Patient reports “I have been Doing a lot of drugs and stupid stuff” Pt was raped 3 weeks ago and has a history of other instances of sexual assault. Had a breakup 3 months ago “that has been affecting me…stupid stuff like sugar daddies…Arguments with parents, walking out of the house, Ubering to guys’ houses late at night”. Stepdad reports “she (pt) is constantly needing someone to be responsible for her emotions, she can’t self-motivate or be happy without a person validating her feelings, if someone rejects her or she has a breakup that kind of sends her spiraling. “Always looking for and always getting into relationships, necessity to find someone”. Support and education provided. Vital are stable and within normal limits B/P-112/67, o2-100, HR-82, T,97.7, wt-125, HT-5’7. Currently she was at home with her biological mother and step father. Family psychiatric history includes major depressive disorder and Generalized Anxiety disorder from Mother, patient does not know her biological father or paternal family history. Patient is single with no children and currently is not in a relationship. She also reported no history of previous pregnancies or abortion. Last Period was last month on 17 June 2022. No medical or Surgical history. Patient reports she has her high school diploma and currently has no plans of going to school. Denied unwanted/negative side effects of medication. No other issues noted/reported. Plan to continue medication regimen with Gabapentin 300 mg x 1 capsules TID oral, Lithium 300 mg x 1 capsule(s)BID, oral, Escitalopram 10 mg x 2 tablet(s), oral, Aripiprazole 15 mg x 1 tablet(s), oral, Prazosin 1 mg x 1 capsule(s), oral. Follow up appointment scheduled.

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