Ensure that you do not include any information that violates the principles of HIPAA (i.e., dont use the patients name or any other identifying information).
State 34 objectives for the presentation that are targeted, clear, use appropriate verbs from Blooms taxonomy, and address what the audience will know or be able to do after viewing.
Present the full complex case study. Include chief complaint; history of present illness; any pertinent past psychiatric, substance use, medical, social, family history; most recent mental status exam; current psychiatric diagnosis including differentials that were ruled out; and plan for treatment and management.
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.
Pose three questions or discussion prompts, based on your presentation, that your colleagues can respond to after viewing your video.
Be succinct in your presentation, and do not exceed 8 minutes. Specifically address the following for the patient, using your SOAP note as a guide.
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 their mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses and why you chose them. List them from highest priority to lowest priority. What was your primary diagnosis, and why? Describe how your primary diagnosis aligns with DSM-5-TR diagnostic criteria and is supported by the patients symptoms.
Plan: What was your plan for psychotherapy (include one health promotion activity and patient education)? What was your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan. Discuss an identified social determinate of health impacting this patients mental health status and provide your recommendation for a referral to assist this patient in meeting this identified need (students will need to conduct research on this topic both in the literature and for community resources).
Reflection notes: What would you do differently with this patient if you could conduct the session again? If you are able to follow up with your patient, explain whether these interventions were successful and why or why not. If you were not able to conduct a follow-up, discuss what your next intervention would be.

Your presentation should include objectives for your audience, at least three possible discussion questions/prompts for your classmates to respond to, and at least five scholarly resources to support your diagnostic reasoning and treatment plan.

CASE STUDY
CC
“Am here for mood stabilization.”
HPI

A 15y/o male patient Started using alcohol at age 13. He last used around July 4th. Drinks 2 times per week. He said he cannot function without drinking. He has been sober since July 4th this year. Drug of choice is marijuana and he last used July 4th. He tried cocaine x1. He denied h/o detox. He said his trigger is peer pressure. The reason he has been sober is because has been in jail and he wants to make his parents happy. Patient reported: “I feel happy. My motivation for this program is to be a role model for my cousins and young ones. No anxiety or depression. No h/o SA. No current SI/HI. No AH or VH. But I used to see shadows when I am under the influence. No feeling of paranoid. H/o violent/aggressive behavior. H/o mood swings. H/o anger management problem. H/o outpatient psychiatric treatment. At that I ran away from home. No inpatient treatment. I was diagnosed with Disruptive Mood Dysregulated Disorder. I used to take Risperidone before and it was later changed to Aripiprazole. H/o multiple arrests x4 for DV and the last arrest was for absconding from house arrest. I have been in jail x2. The last jail was from July to September 10, 2022. Sleep is good and no issues with appetite

PMHX: Denied

Allergies: Avocado

PSHX: Cholecyctectomy/

VITALS : BP:120/53 , HR 66 , RR 16 Temp 98.5 Ht 5 10 Wt 149lb BMI 21.41 spo2 98.0%

Psych FHX
Family history of mental illness: Dad has anger management problem
Family history of suicide: Denied
Family history of substance abuse: Mom used to struggle with alcohol, but she has quit drinking

Social HX
Patient graduated high school, single, unemployed, residing at residential treatment center. Patient was physically and emotionally abused by step mom.

Medications
ARIPiprazole 5 mg tablet, Take 1 tablet by mouth in the morning
hydrOXYzine HCL 25 mg tablet, Take 1 tablet by mouth at bedtime
divalproex 250 mg tablet,delayed release, Take 1 tab by mouth at bedtime

Examination
Patient is A/O x3. Appears neat, nourished, groomed for stated age. Patient was cooperative and. maintained good eye contact during interview. Speech is normal, preferred language is English

DSM-5
(F39) Unspecified mood [affective] disorder modified
(F91.2) Conduct disorder, adolescent-onset type
(F12.10) Cannabis abuse, uncomplicated
(F10.10) Alcohol abuse, uncomplicated