State 3-4 objectives for the presentation that are targeted, clear, use appropriate verbs from Bloom’s taxonomy, and address what the audience will know or be able to do after viewing.

Week (enter week #): (Enter assignment title)

PMHNP Care Across the Lifespan I

Faculty Name

Assignment Due Date

Subjective:

CC (chief complaint):

1. HPI: B: L is 59 years AA female who presents with feeling anxious Stated she was high jacked twice and lost her car twice in gun point, says two young boys high jacked her car in gun point which is increasing her paranoid thoughts and feel very anxious when she goes out. Patient admits going through lot of stress and lost so much money and getting more sicker and says her stress level and anxiety level is high. Says recently she is looking the surroundings and feels somebody is watching her after the incidents and feel more paranoid. Patient admits she is worried about her physical condition also say she lost 40 IBS in 8 months and says her blood sugar is uncontrollable . Patient stated she feel more anxious about her weight loss says she feels like her energy is leaving off from her muscles and say she is really curious about huge weight lost and say she is looking like skeleton. Patient is alert and oriented x4, communicating good, cooperative with the assessment. Her appearance is age appropriate thin body built. Her speech is normal is rate and volume. Patient Dx with Anxiety , Depression mood, anhedonia, insomnia, Fatigue and difficulty concentrating and adjustment disorder. Patient stated on Vistaril 25 mg BID PRN . Follow up in four 4-week Plan is to continue current medications.

Substance Current Use:

Medical History:

· Current Medications:

· Allergies:

· Reproductive Hx:

ROS:

· GENERAL:

· HEENT:

· SKIN:

· CARDIOVASCULAR:

· RESPIRATORY:

· GASTROINTESTINAL:

· GENITOURINARY:

· NEUROLOGICAL:

· MUSCULOSKELETAL:

· HEMATOLOGIC:

· LYMPHATICS:

· ENDOCRINOLOGIC:

Objective:

Diagnostic results:

Assessment:

Mental Status Examination:

Diagnostic Impression:

Anxiety ,

Depression mood,

Anhedonia,

insomnia,

Fatigue and difficulty concentrating and adjustment disorder.

Reflections:

Case Formulation and Treatment Plan: 

,

· State 3–4 objectives for the presentation that are targeted, clear, use appropriate verbs from Bloom’s 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 patient’s 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 patient’s 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.

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