Client is a 10 yo HM who has been in DFPS custody before, moved to FL for adoption of himself and siblings, 6 to 8 mos later, the adoption fell through and he is now back in the system. His mother died in a car accident while he was in DFPS custody. Client has frequent SI/HI verbalized threats with aggression towards others. Client continues to present with anxious affect and labile mood. Upon arrival, client could be heard outside (although he was indoors) having a verbally aggressive tantrum with yelling, screaming, crying, blaming and oppositional defiant behaviors. Despite the foster mom’s quiet calm tone and attempts to hear him out, he continued to lash out verbally. Foster mom informed me client has been picking at his fingernail bed until it bleeds and has been peeling the skin from around his toenail bed with his teeth until it bleeds. She is afraid of infection and discussed a doctor’s visit with the client, which appears to have triggered the outburst. Client became increasingly frustrated and agitated as took a seat. He continued the restricted disclosure until finally, therapist responded to the client in a quiet voice, “Okay, I’m listening. Tell me exactly what it is that you want.” Client began to escalate again, while whining and yelling, he began to blame again stating we were not listening to him. Therapist quietly again called him by name twice and stated calmly, “Just take a deep breath. Take another one, now another one. Now, I’m listening, just tell me what you want.” Client covered his ears with his hands then his eyes and yelled (but in a lower volume), I want my privacy! I don’t like people looking at my privacy!” Therapist asked client what he meant by his privacy. Client responded he didn’t want people looking at his pictures of his family or his younger self. He also stated he did not want to go to the hospital because she (FM) was just going to send him away to another home. Foster mom offered to put his photos in a photo album that he could access whenever he chose to do so. She also reassured him that he was not going to the hospital or going to be discharged from her home. She explained to him she was going to accompany him to the doctor so they could properly attend to his wounds and therapist supported her statement verbally. We discussed managing our emotions in healthy ways and using our coping skills including mindful/ deep breathing. Client shared some drawings he made and therapist encouraged him to utilize drawing to self-soothe. Client was given time to draw and color (about 10 minutes) and he offered another drawing to the therapist. Next session will focus on emotional regulation and mindfulness.
· Review this week's Learning Resources and consider the insights they provide about impulse-control and conduct disorders.
· Select a patient for whom you conducted psychotherapy for an impulse control or conduct disorderduring the last 6 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 evaluation note as a Word document and pdf/images of 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 Kaltura Media Uploader resource in the left-hand navigation of the classroom for help creating your self-recorded Kaltura video.
· 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.
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.
· 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.
submission information – Part 1: Recording
To submit your video response entry:
1. Click on Start Assignment near the top of the page.
2. Next, click Text Entry and then click the Embed Kaltura Media button.
3. Select your recorded video under My Media.
4. Check the box for the End-User License Agreement and select Submit Assignment for review.
submission information – Part 2: Comprehensive Psychiatric Evaluation Note
To submit Part 2 of this Assignment, click on the following link:
Rubric
PRAC_6645_Week7_Assignment2_PT1_Rubric
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PRAC_6645_Week7_Assignment2_PT1_Rubric |
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Criteria |
Ratings |
Pts |
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This criterion is linked to a Learning OutcomePhoto ID display and professional attire |
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5 pts |
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This criterion is linked to a Learning OutcomeTime |
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5 pts |
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This criterion is linked to a Learning OutcomeDiscuss Subjective data:• Chief complaint• History of present illness (HPI)• Medications• Psychotherapy or previous psychiatric diagnosis• Pertinent histories and/or ROS |
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10 pts |
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This criterion is linked to a Learning OutcomeDiscuss Objective data:• Physical exam documentation of systems pertinent to the chief complaint, HPI, and history• Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses |
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10 pts |
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This criterion is linked to a Learning OutcomeDiscuss results of Assessment:• Results of the mental status examination• 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 diagnostic criteria and is supported by the patient’s symptoms. |
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20 pts |
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This criterion is linked to a Learning OutcomeDiscuss treatment Plan:• A treatment plan for the patient that addresses psychotherapy and rationales including a plan for follow-up parameters and referrals |
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20 pts |
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This criterion is linked to a Learning OutcomePresentation style |
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5 pts |
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Total Points: 75 |
