• There is also a completed exemplar document attached so that you can see an example of the types of information a completed evaluation document should contain.
Develop a case presentation, based on your evaluation of this patient below, SEE Case History Reports below
• 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.
• 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.
• Include at least five (5) scholarly resources to support your assessment and diagnostic reasoning.
• 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 History Reports:
The patient is a 31-year-old unemployed, single African American male, residing with his mother in the states of Maryland. Patient is a part time student at University of Maryland studying music. Vitals: T- 98.5, P- 70, R 23 148/84 Ht 5’8 Wt = 200lbs. Pt. is alert, oriented X3. Pt. was referred by his social worker for evaluation and treatment of schizoaffective disorder- Bipolar Type without Catatonia, Multiple Episodes, Anxiety, and ADHD. Patient`s illness started when he was in high school. He resisted treatment until three years ago after mental breakdown. Pt states "I’m doing ok" when prompted. Added, I only want to take Abilify Maintena 400 mg IM every 4 weeks for targeting psychosis and sleep. Pt no longer will take Clozaril (clozapine) 200 mg po BID or Depakote (valproic acid) 750 mg po BID targeting mood stability due to negative side effect. Pt states that all his pills were discontinued during his last hospitalization months ago. “I opted for injection only”. Patient has a long history of sudden relapses and poor decisions regarding his psychotropic medications. Hopefully, he will fare well enough only taking Abilify. He denies any notable adverse effects from his Abilify Maintena 400 mg IM. This pt reports sleeping about 8 uninterrupted nightly hours with stable daytime energy and appetite. The pt denies any paranoid or delusional ideations. The pt denies any SI or HI and has no intent or plans for same. Pt states that he was released about 5 months ago from inpatient psychiatric hospitalization at the Psychiatric Institute of Maryland (PIW) after having discontinued taking his psychiatric medications and then began hearing irritable voices in his head with self-harming thoughts. Pt’s condition may also have been aggravated by the fact that he also stopped taking his diabetic and antihypertensive medications. Mental review completed. His speech is regular rate, volume and prosody. Mood was euthymic with limited range of vocal affect. Mood is 7-8/10 with 10 = best mood. Pt denies any current hallucinations, no evidence of delusions or mania or paranoia. Cognition was grossly intact. Insight & judgment are fair to poor. The patient denies SI or HI and has no intent or plans for same. Pt denies experiencing any restlessness. Allergies Reported by Patient: Bactrim, Amoxicillin. Pt. drinks about 5 bottles of beer/week. Pt. doesn’t smoke
Sample Solution