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UMBC Comprehensive Psychiatric Evaluation Case Study

 

Select a patient that you examined during the last 5 weeks. Review prior resources on the disorder this patient has. Also review the Kaltura Media Uploader resource in the left-hand navigation of the classroom for help creating your self-recorded Kaltura video.

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.

  • Develop a video case presentation, based on your progress note of this patient, 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.

  • CASE STUDY: JD is a 58 years old African American male, who was seen via telehealth for psychiatric evaluation. Patient chief complain was Anxiety and Panic attack with Sleep disorder, with symptoms of irritability, restlessness because he can’t find enough to do. Patient report nervousness and sleep disturbance. Patient report that he  feel overwhelmed and get frequent panic attacks. Patient report family history of anxiety disorder (Father), patient also report illicit substance use. Patient stated that he is not taking any medication for now. He denied AH/VH and SI/HI. Patient was started on Buspirone 20mg BID, Nortriptyline 100mg QHS, Trazodone 100mg QHS. Urine tox profile and EKG ordered and to follow up with the clinic in 30 days. Patient was inform, if you think you are experiencing a psychiatric emergency, including suicidal or homicidal thoughts, plans, or actions, call Baltimore Crisis Response at 410-433-5175 or the National Suicide Prevention Hotline at 1-800-273-8255. If you cannot reach any of these numbers, call 911 or go to the nearest ER.