Select a patient you have encountered in the clinic setting who has signs and symptoms of at least three psychiatric disorders
1. You are assigned a diagnosis. Next, Select a patient you have encountered in the clinic setting who has signs and symptoms of at least three psychiatric disorders and one medical condition to create the case.
2. Provide a 10-12 PPT slide overview of the case using Zoom.
S=
Subjective data: Patient’s Chief Complaint (CC); History of the Present Illness (HPI)/ Demographics; History of the Present Illness (HPI) that includes the presenting problem and the 8 dimensions of the problem (OLDCARTS or PQRST); Review of Systems (ROS).
O=
Objective data: Medications; Allergies; Past medical history; Family history; Past surgical history; Psychiatric history, Social history; Labs and screening tools; Vital signs; Physical exam(Focused), and Mental Status Exam.
A=
Assessment: Primary Diagnosis and two differential diagnoses including ICD-10 and DSM5 codes.
P=
Plan: Pharmacologic and Non-pharmacologic treatment plan; diagnostic testing/screening tools, patient/family teaching, referral, and follow-up.
Other: Incorporate current clinical guidelines NIH Clinical GuidelinesLinks to an external site. or APA Clinical GuidelinesLinks to an external site. , research articles, and the role of the PMHNP in your presentation.
· Graduate Mental Status Exam Guide Download Graduate Mental Status Exam Guide
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Reminder: It is important that you complete this assessment using your critical thinking skills. You are expected to synthesize your clinical assessment, formulate a psychiatric diagnosis, and develop a treatment plan independently. It is not acceptable to document “my preceptor made this diagnosis.” An example of the appropriate descriptors of the clinical evaluation is listed below. It is not acceptable to document “within normal limits.”
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