For this assignment, you will develop a realistic clinical case presentation. Use PowerPoint to create the slides for your presentation. You will record narration for the slides in the next assignment, so keep that in mind as you work.
Content Requirements
You will create a PowerPoint presentation with a realistic case study and include appropriate and pertinent clinical information based on the DSM5-TR and current US clinical guidelines to support the case:
Subjective data:
Chief Complaint ( chief complaint " patient stated" " patient expressed") Includes a direct quote from the patient about presenting problem.
Demographics (name, DOB, race, male or female) Begin with patient initials, age, race, ethnicity, and gender (5 demographics).
History of the Present Illness (HPI) includes the presenting problem and the 8 dimensions of the problem. Includes the presenting problem and the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing, and Severity).
Review of Systems (ROS) includes a minimum of 3 assessments for each body system, assesses at least 9 body systems directed to the chief complaint, AND uses the words “admits” and “denies”.
Objective data:
Current Medications (Includes a list of all of the patient-reported psychiatric and medical medications and the diagnosis for the medication (including name, dose, route, and frequency).
Allergies (Includes NKA (including = Drug, Environmental, Food, Herbal, and/or Latex or if allergies are present (reports for each severity of allergy AND description of allergy).
Past medical history ( Including (Major/Chronic, Trauma, Hospitalizations), for each medical diagnosis, year of diagnosis, and whether the diagnosis is active or current.
Family psychiatric history (Includes an assessment of at least 6 family members regarding, at a minimum, genetic disorders, mood disorder, bipolar disorder, and history of suicidal attempts.
Past surgical history
Past Psychiatric History ( includes (Outpatient and Hospitalizations), for each psychiatric diagnosis (including addiction treatment), year of diagnosis and.
Social history
Labs and screening tools (Includes a list of the labs, diagnostic tests, or screening tools that should be completed for identified patients that are based on the US clinical guidelines OR acknowledge no labs/diagnostic tests are recommended.
Vital signs (Include all 8 vital signs, (BP (with patient position), HR, RR, temperature (with Fahrenheit or Celsius and route of temperature collection), weight, height, BMI (or percentiles for pediatric population), and pain.).
Mental Status Exam (Includes all 10 components of the mental status exam (appearance, attitude/behavior, mood, affect, speech, thought process, thought content/ perception, cognition, insight and judgement) with detailed descriptions for each area.
Assessment:
Primary Diagnosis - DSM5 only (avoid talking in the third person) Includes a clear outline of the accurate principal diagnosis based on DSM5 or DSM5-TR criteria.
Differential diagnosis - DSM5 onlyIncludes at least 2 differential diagnoses for the principal diagnosis.
Plan:
Pharmacologic treatment plan ( include medication, name, daily dose, retail price, and contraindications for this drug) Includes a detailed pharmacologic and non-pharmacological treatment plan for each of the diagnoses listed under “assessment”. The plan includes ALL of the following: drug/vitamin/herbal name, dose, route, frequency, duration and cost as well as education related to pharmacologic agent. For non-pharmacological treatment, includes: treatment name, frequency, and duration. If the diagnosis is a chronic problem, include instructions on currently prescribed medications as above.
Non-pharmacologic treatment plan (transcranial magnetic stimulation)
Follow up plan
Other:
Incorporation of current US clinical guidelines
Integration of research articles
Role of the nurse practitioner (let's avoid talking in the third person) (use I recommend, I prescribed )
