Diagnostic Reasoning and Treatment Plan

Your presentation should include objectives for your audience, at least 3 possible discussion questions/prompts for your classmates to respond to, and at least 5 scholarly resources to support your diagnostic reasoning 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.

o 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?
o Objective: What observations did you make during the psychiatric assessment?
o 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.
o 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).
o 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.

Patient:

SBL is a 24-year-old Female with history of bipolar disorder, severe with psychotic features, anxiety and substance abuse (OUD, Cannabis use disorder) and PTSD who is seen virtually for medication management and follow-up. Patient reports, “I’m ok”. She recently visited her ob/gyn due to amenorrhea x 4 years. Reports that she had lab work drawn, and results revealed elevated prolactin levels 170 and low TSH level -0.15. Her doctor recommended that the Zyprexa be discontinued. Patient reports meds have been effective; however, she does endorse breast discharge. Patient states that she was initially started on an antipsychotic medication (Risperdal) in May of 2020. According to pt, a previous trial of Lamictal made her “act bizarre”. Taper off of Zyprexa decreased dose to 7.5 mg x2 weeks. Will trial Depakote starting at 250 mg BID.TSH and Prolactin levels have been ordered. Patient reports that she has not needed to take the Suboxone, denying any cravings. Patient denies any SI/HI or manic behaviors.

Initial Assessment
Patient is a 23-year-old female with history of Bipolar d/o, Borderline Personality Disorder, Post Traumatic Stress Disorder that was seen today for an initial evaluation. Patient stated ” I stopped taking my medication because my previous psychiatrist was not listening to me”

Patient stated that she was previously prescribed Risperidone 8 mg and stopped taking it early January. Patient stated ” I kept telling him that the higher dose was making me manic, I was overspending and he didn’t listen when I told him I wanted to decrease the dose”

Patient stated that Risperidone was increased to 8 mg to help with anxiety after Buspirone was discontinued.

Patient stated ” I am not doing good and I know I need to get back on my meds”. Patient stated ” I was able to function when I was taking 2 mg in the AM and 2 mg at bedtime”

Patient reports labile mood. Patient reports Insomnia. “Last week had a few days that I did not sleep at all”. Patient reports Paranoia. The patient stated ” I get paranoid when I am driving. I feel like there are people following me. I get home and I feel this presence, an entity around me”
Patient reports intermittent suicidal ideations. The patient states that she last had suicidal thoughts 4 days ago. She denies current plans or intent. Patient stated, ” I’ve always had suicidal thoughts since I was a child.”
Patient reports multiple suicide attempts. Starting at 7 years old.
Patient stated ” There have been times I think about it, I take the pill bottles out with the thought to do it, and then I get a phone call and I think, someone cares about me so I won’t do it”

Patient states that her son’s father died by suicide and she would not want to leave her son without a parent.

PROTECTIVE FACTORS:
The patient endorses several protective factors contributing to a reduction in the likelihood of engaging in self-injurious behavior, including attempting or completing suicide:
[x ] Close relationships with family members whom they would not want to be affected by such acts.
[ ] Commitment to occupational/school related activities.
[ ] Animals patient cares for/about.
[ ] Future engagements and activities in which they wish to participate.
[ ] Therapeutic alliance with outpatient medical or psychological providers.
[ ] Religiosity.
[ ] A sense of hope.
[ ] Other:

Allergies

Seroquel facial tics, dexamethasone itchy throat & eyes, sulfa need EpiPen,

Required Readings
• Carlat, D. J. (2017). The psychiatric interview (4th ed.). Wolters Kluwer.
o Chapters 31, “Assessing Personality Disorders”
o Chapter 32, “How to Educate Your Patient”
• Office of Disease Prevention and Health Promotion. (n.d.). Social Determinates of Health. Links to an external site. Healthy People 2030. U.S. Department of Health and Human Services. https://health.gov/healthypeople/priority-areas/social-determinants-health
Recommended Readings
• American Psychiatric Association. (2010). Practice guideline for the treatment of patients with borderline personality disorderLinks to an external site.. https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/bpd.pdf
• Oldham, J. M. (2005). Guideline watch: Practice guideline for the treatment of patients with borderline personality disorderLinks to an external site.. American Psychiatric Association. https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/bpd-watch.pdfLinks to an external site.
• Boland, R. Verdiun, M. L. & Ruiz, P. (2022). Kaplan & Sadock’s synopsis of psychiatry (12th ed.). Wolters Kluwer.
Recommended Media
• Grande, T. (2018, Nov. 30). What are paraphilic disorders? Links to an external site. [Video]. YouTube. https://www.youtube.com/watch?v=YOV61lKxqxY
• Taylor Study Method. (2014, Aug. 18) Paraphilic disordersLinks to an external site.. [Video]. YouTube. https://www.youtube.com/watch?v=0TtryBLokZc