Assignment

· 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

· 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/ 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?

Case Study

26-year-old white female. Individual is A/O x3. Individual reports “everything hit me like a freight train in January. I could not sleep.” Individual reports she was placed on medication during recent inpatient admission to psychiatric facility. Individual reports “it works a little too well. It makes me sleepy.” She reports originally going to the psychiatric facility because she could not sleep. Individual reports being diagnosed with Bipolar disorder. She reports losing 14 pounds within one week. Individual reports taking Gabapentin 600 mg in the morning, 600 mg at noon, and 1200 mg at night, and Abilify 5 mg at night. Individual complains of sleeping too much at night. Individual rates life 8/10 with 10 being total happiness. She denies S/I, H/I. individual reports that she has highs and lows. She reports she tried Lithium during inpatient admission “I had a really bad reaction. I had diarrhea.” DX; Bipolar I disorder; Mild depression. Plan; Gabapentin 600 mg tablet, 1.5 tablet nightly, Gabapentin 600 mg one tablet twice daily, Aripiprazole 5 mg one tablet nightly.

DX;

Bipolar disorder, Depression

Medications

Gabapentin 600 mg 1.5 tab nightly

Gabapentin 600 mg one tab daily

Aripiprazole 5 mg tab nightly

Mental exam

PHQ-9 total score; 4

GAD-7 total score; 7

Assessment

Mild depression (disorder) (f32.0/296.21) Major depressive disorder, single episode, mild modified.

Bipolar I disorder (disorder) (f31.9/296.80) Bipolar disorder, unspecified.

Plan;

“I wanna continue going on the right track.” Continue all medications as ordered.

Vital signs

BP; 122/75

HR; 88 bpm

Ht/Lt; 5’11”

Wt; 153 lbs 9 oz

BMI; 21.42

Pain; 0/10