Client Evaluation PowerPoint Presentation

Client Evaluation PowerPoint Presentation

Client is a 44 yo MBF with marital discord, daily THC use, TMS (Transcranial Magnetic Stimulation) treatment DX: F31.63 – Bipolar Disorder, Current episode mixed, severe, w/o psychotic features Rx: Adderall XR 20 mg Allergies: N/A Client is a 44 yo MBF whose husband of 20 yrs left in January 2024. Seeking to gain clarity. Currently getting a divorce. Her boxer also had a brain tumor and underwent treatment for weeks. SHe caught him cheating but admits she was able to do whatever she wanted to and. She also just lost her mom to death. Check tips on how to do your Nursing Presentation Assignment. 

Client self rpts: decreased appetite, trouble concentrating, difficulty sleeping, SIB episodes leading to her Husband needing to take FMLA every 3 mos, low motivation, fatigue/low energy, anxiety, fear, hopelessness, depressed mood, hormone-related problems, angina or chest pain, bone or joint problems, infertility. Some grief/ loss issues re: never conceiving. She miscarried in 2008. She has done DBT in the past and has been DX with OCD Personality D/O. Her mom died 05/18/2018 with multiple health issues including sepsis. Her mom lived with them for 8 yrs. She has also had multiple deaths in her family around her mom’s death including one of her brothers.

Client Evaluation PowerPoint Presentation

She rpts her husband would always explain away fishy situations but has never taken responsibility for cheating even when caught. She put a tracker on his phone after some change in his behxs leading her to believe he was cheating. She has gone to arbitration for 5 hrs and had an agreement but he left refusing to sign anything. She has not worked in years but recently got a job at FedEx working nights and UPS driving (begins tomorrow). Her dad has given him $50K to payoff bills.

Her husb has been physically abusive with her – she rpts an incident where choked her in the tub after confronting him about cheating. Some rapid pressured speech, tearful crying spells, rambling, rumination. She is doing TMS and her last use was 2 days ago. Past medications Focalin and Klonopin. She has Klonopin as PRN but has not taken it. She rpts no nightmares, difficulty sleeping or cigarette use since her husband left. She rpts last episode of SIB yesterday due to feeling trapped and anxious and hitting herself. Her last episode of SI thoughts/ behx is unknown. Client is rather attached to her MD and unwilling to get treatment from anyone else.

Client Evaluation PowerPoint Presentation

• Review this week’s Learning Resources and consider the insights they provide about clinical practice guidelines.
• Select a group patient for whom you conducted psychotherapy for a mood disorderduring the last 4 weeks. Create a Comprehensive Psychiatric Evaluation Note on this patient using the template provided in the Learning Resources. There is also a completed template provided as an exemplar and guide. All psychiatric evaluation notes must be signed by your Preceptor. When you submit your note, you should include the complete comprehensive psychiatric evaluation note as a Word document and pdf/images the completed assignment signed by your Preceptor. You must submit your note using Turnitin. Please Note: Electronic signatures are not accepted. If both files are not received by the due date, Faculty will deduct points per the Walden Grading Policy.
• Then, based on your evaluation of this patient, develop a video presentation of the case. Plan your presentation using the Assignment rubric and rehearse what you plan to say. Be sure to review the Kalturasupport resources in the Classroom Support Center found by clicking on the Help
• Include at least five scholarly resources to support your assessment and diagnostic reasoning.
• Ensure that you have the appropriate lighting and equipment to record the presentation.

Client Evaluation PowerPoint Presentation

The Assignment

Record yourself presenting the complex case for your clinical patient.

Do not sit and read your written evaluation! The video portion of the assignment is a simulation to demonstrate your ability to succinctly and effectively present a complex case to a colleague for a case consultation. The written portion of this assignment is a simulation for you to demonstrate to the faculty your ability to document the complex case as you would in an electronic medical record. The written portion of the assignment will be used as a guide for faculty to review your video to determine if you are omitting pertinent information or including non-essential information during your case staffing consultation video.

In your presentation:

• Dress professionally and present yourself in a professional manner.
• Display your photo ID at the start of the video when you introduce yourself.
• Ensure that you do not include any information that violates the principles of HIPAA (i.e., don’t use the patient’s name or any other identifying information).
• Present the full complex case study. Be succinct in your presentation, and do not exceed 8 minutes. Include subjective and objective data; assessment from most recent mental status exam; current psychiatric diagnosis including differentials that were ruled out; current psychotherapeutic plan (include one health promotion activity and one patient education strategy you provided); and patient progress toward treatment goals.

Client Evaluation PowerPoint Presentation

• Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What was 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 the patient’s mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses in order of highest to lowest priority and explain why you chose them. 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: Describe your treatment modality and your plan for psychotherapy. Explain the principles of psychotherapy that underline your chosen treatment plan to support your rationale for the chosen psychotherapy framework. What were your follow-up plan and parameters? What referrals would you make or recommend as a result of this psychotherapy session?

• Reflection notes: What would you do differently in a similar patient evaluation? Reflect on 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.