Reference no: EM133498744

Assignment: Psychopathology and Diagnostic Reasoning Paper

Select a group patient for whom you conducted psychotherapy for a mood disorder during the last 4 weeks. Create a Comprehensive Psychiatric Evaluation Note on this patient using the template provided in the Learning Resources. There is also a completed template provided as an exemplar and guide. All psychiatric evaluation notes must be signed, and each page must be initialed by your Preceptor. When you submit your note, you should include the complete comprehensive psychiatric evaluation note as a Word document and pdf/images of each page that is initialed and signed by your Preceptor.

Note: Electronic signatures are not accepted. If both files are not received by the due date, Faculty will deduct points per the Walden Grading Policy.

1. Then, based on your evaluation of this patient, develop a video presentation of the case. Plan your presentation using the Assignment rubric and rehearse what you plan to say. Be sure to review the Kaltura support resources in the Classroom Support Center found by clicking on the Help button.

2. Include at least five scholarly resources to support your assessment and diagnostic reasoning.

3. Ensure that you have the appropriate lighting and equipment to record the presentation.

Task

Record yourself presenting the complex case for your clinical patient.

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:

Question 1. Dress professionally and present yourself in a professional manner.

Question 2. Display your photo ID at the start of the video when you introduce yourself.

Question 3. 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).

Question 4. Present the full complex case study. Be succinct in your presentation, and do not exceed 8 minutes. Include subjective and objective data; assessment from most recent mental status exam; current psychiatric diagnosis including differentials that were ruled out; current psychotherapeutic plan (include one health promotion activity and one patient education strategy you provided); and patient progress toward treatment goals.

Question A. Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What was the duration and severity of their symptoms? How are their symptoms impacting their functioning in life?

Question B. Objective: What observations did you make during the psychiatric assessment?

Question C. Assessment: Discuss the patient's mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses in order of highest to lowest priority and explain why you chose them. What was your primary diagnosis and why? Describe how your primary diagnosis aligns with DSM-5-TR diagnostic criteria and is supported by the patient's symptoms.

Question D. Plan: Describe your treatment modality and your plan for psychotherapy. Explain the principles of psychotherapy that underline your chosen treatment plan to support your rationale for the chosen psychotherapy framework. What were your follow-up plan and parameters? What referrals would you make or recommend as a result of this psychotherapy session?

Question E. 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.

Scenario

H.J is a 28 YO AA female who presented to the clinic today accompanied by her parents and seeking to establish care today for medication management.

Chief Compliant: She reports trouble falling asleep and staying asleep. She says that she has been waking up every 2 hours and has been feeling tired during the day, she has not been taking care of her basis needs and has been shutting everyone out and self-isolating. Patient reports her entire family suffer from mental health Issues: mom suffers from Depression; other siblings are all diagnosed with depression. Pt stated that she had a normal childhood and grow up in an average AA family and neighborhood. She denies any current SI thoughts but states she is depressed. She reports her family called Mobile Crisis 2 weeks ago and she was admitted at the hospital due to SI attempt. Patient reports tried to overdose on Acetaminophen. Patient reports she has been doing great since discharge. Patient reports she currently smokes Marijuana because it keeps her calm. She reports she was prescribed Wellbutrin in the past but she will like to try something else

Diagnosis: Depression
Medications: Seroquel

Plan: Patient is encouraged to start this new medication regimes, and she will use deep breathing techniques and relaxation techniques to help alleviate her Depression. Patients are encouraged to also utilize positive coping skills and maintain a healthy lifestyle for a positive outcome. Patient was encouraged to think about seeing a therapist and said she will give it some thought. she was encouraged to call the office and communicate any concerns to practitioner and verbalized understanding.