Student Notes Patient is a 68yo F with PPHx. of Schizoaffective disorder and stimulant (cocaine) use disorder and PMHx. of HTN, CKD, anemia, Afib who presents to crisis under PC after ingesting unknown number of pills and endorsing suicidal thoughts. Patient is hostile, uncooperative, restless and irritable during interview; history limited due to irritability. Patient endorses having taken an unknown number of pills, cannot recall the name of the pills with the intention to “hurt [herself]”. Patient states she has had suicidal ideations chronically, from “years ago”. Patient denies past suicidal attempts and history of self-injurious behavior. She also denies symptoms of depression such as anhedonia, low energy, sleep disturbances and difficulty concentrating. Patient denies homicidal ideation. Patient endorses persecutory delusions and auditory hallucinations although she is unable to further elaborate on their content. Patient endorses crack cocaine use with last use being 2 days ago, she cannot tell the amount consumed. She denies use of other illicit drugs including alcohol. UTOX positive for cocaine and metabolites. Patient endorses medication non-adherence and is currently homeless. Cocaine use disorder (ICD10-CM F14.10, Discharge, Medical) *Probable Unspecified mood [affective] disorder (ICD10-CM F39, Discharge, Medical) *Probable Acute psychosis (ICD10-CM F23, Discharge, Medical) Plan: -Admit to Inpatient, Involuntary -Meds: -Psychotropic: ETOs only -Medical: Seroquel 50mg BID, Remeron 15mg, QHS, QHS -Labs: -Safety: No 1:1 sitter acutely indicated at this time. Continue current level of inpatient staff observation. Discussed with team and will continue to monitor and treat as indicated.
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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 diagnostic criteria and supported by the patient’s symptoms. Assess them by talking about the results of the mental status exam. What different diagnoses did you make? Give at least three possible diagnoses and explain why you picked them. List them from most important to least important. What was your main diagnosis, and why was it that way? Explain how your main diagnosis fits with the DSM-5 diagnostic criteria and how the patient’s symptoms back up your main diagnosis.
Plan: In your video, describe your treatment plan using clinical practice guidelines supported by evidence-based practice. Include a discussion on your chosen FDA-approved psychopharmacologic agents and include alternative treatments available and supported by valid research. All treatment choices must have a discussion of your rationale for the choice supported by valid research. What were your follow-up plan and parameters? What referrals would you make or recommend as a result of this treatment session?
In your written plan include all the above as well as include 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.
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.
