POWER POINT CASE PRESENTATION

Instructions

Case Study Presentations

Purpose: The purpose of this assignment is to practice, in a grand rounds format, the written and verbal ability to present a client and overall plan of care to your peers. Select one client from your practicum experience for the presentation. You will be assigned a date to present via scheduled webinar. Webinars will be scheduled at the instructors discretion.

Format and Expectations for Case Study Presentations:

1. The case study should be prepared with Microsoft Power Point. The presentation time should not exceed 30 minutes. Voice-over formats are not permitted, and the case study must be presented live via webinar to your instructor and classmates.
2. The client presented in the case study presentation cannot be any other client you presented in any other assignment.
3. The presentation should follow the format of the psychiatric evaluation and be presented in an organized, logical, thorough, yet concise manner. Patient goals and treatment rationales with neurobiology should be included. The Grading Rubric for Psychiatric Evaluations will be utilized for grading purposes.

RUBRIC

Rubric

1. Demographic Data

Includes identifying information including initials, age, gender, ethnicity. Primary source of information and reliability as well as reason for referral and patient understanding of referral are clear.

2. Subjective : History of Present Illness

CC is clear, concise and verbatim from pt. HPI is thorough yet concise and provides a chronological account of symptoms and contextual factors that are sufficiently descriptive (oldcarts) to validate Dx per DSM-5 criteria. All pertinent negatives are included. A longitudinal course of illness is clear. Current psychiatric medications and response are included.

3. Past Psychiatric History

PPH contains all previous treatment including previous Dx, hospitalizations, outpatient treatments, suicide attempts, self-harm, and previous medications with detailed trial and response history. Pertinent negatives are also included.

4. Substance Use History

Complete substance use history is documented. Pertinent negatives are clear evidenced by appropriate pt. responses ie. denies. Age of onset, duration, frequency/pattern of use, route of administration, last use, consequences of use. Not limited to illicit substances. Inclusive of addictive behavioral patterns.

5. Past medical history and review of symptoms

Medical history includes previous and current medical problems, surgeries, and allergies. ROS is germane to the presenting psychiatric problems and is free from objective assessment data ie. lungs clear BS present.

6. Family History Psychosocial and Developmental History

Family Hx includes identified relational status with current or historical psych illness, treatments, responses, suicides, or self-harm. Indication if biologically related. Devt Hx includes info regarding family of origin, siblings, birth order, family dynamics, relational patterns and status, educational, employment, abuse, spirituality, legal, military. Devt milestones for child & adolescents are included

7. .Objective Data Mental Status Exam Physical Exam (as appropriate) vital signs, height, weight, labs or other relevant

MSE contains all elements as outlined in addendum..

Is in narrative form and effectively and vividly describes the patients presentation. Concrete examples of all assessment results are included ie. able to correctly interpret 2/3 simple proverbs to validate documentation of abstract thought intact.

8. Assessment

Differential is pertinent to S&S, formulation contains evidence of critical thought and subject knowledge, and reasonable diagnoses are made per DSM-5. Clearly met criteria for diagnoses tendered are explicit in the HPI description and substantiated with the MSE.

9. Plan

Evidence-based treatment plan is presented with detailed rationales. Level of detail reflects the students ability to choose treatments based not only on FDA approval or current evidence but also the nuances and unique characteristics of each. Treatment plan is holistic and comprehensive. There is strong evidence of the students synthesis of information and critical thought.

10. Writing, support APA

The format is consistent with the example provided in the course. Strong, recent (5-7 years), scholarly, peer- reviewed support of topics. No grammar, spelling, and punctuation errors. Writing mechanics are consistent with formal scholarly work. No errors in APA style based upon the required APA manuals listed on the course syllabi

INFORMATION ABOUT THE PATIENT.

Name: JA

Age 79yr old

Time of Encounter: 3/2/2026

Subjective:

Patient states he is hanging in there and that he does not know why he is back in the hospital. Per wife at bedside, she was dissatisfied with the care he received at the rehab facility after pt was discharged from PYP Hospital on 2/27 and reports that he has been experiencing periods of confusion.

Objective

Visit Vitals

BP 109/55 (BP Location: Left arm)

Pulse 63

Temp 37.3 C (99.1 F) (Oral)

Resp 18

Ht 1.778 m

Wt 81.7 kg

SpO2 91%

BMI 25.84 kg/m2

Smoking Status Former

BSA 2.01 m2

Mental Status Examination:

Appearance: Wearing hospital scrubs and In no apparent distress

Behavior: Calm and Cooperative

Psychomotor: Calm; No EPS, Tremors, or Tics Noted

Speech: Slowed rate, Decreased volume, and Mumbled

Mood: “hanging in there”

Affect: Appropriate and Normal range

Thought Process: Linear and Goal-directed

Thought Content

-Suicidal Ideation: Denies Suicidal Ideation

-Homicidal Ideation: Denies Homicidal Ideation

-Delusions/Paranoia: No evidence of Paranoia/Delusions

Perception

-Hallucinations: Denies Auditory Hallucinations, Denies Visual Hallucinations

-Internal Preoccupation: Does not appear internally preoccupied

Attention: Fair

Concentration: Fair

Recent Memory: Fair

Remote Memory: Fair

Insight: Fair

Judgement: Limited

Impulse Control: Limited

Medication

cloNIDine 0.1 mg oral q12h

haloperidoL lactate 2 mg intravenous At bedtime

lamoTRIgine 200 mg oral BID

sertraline 50 mg oral Daily

haloperidoL lactate 2 mg intravenous q4h PRN

Or

haloperidol 2 mg oral q4h PRN

EKG:

2/28/2026: Qtc 408

Sinus Rhythm With Occasional Premature Ventricular Complexes

T Wave Abnormality, Consider Inferior Ischemia

Abnormal Ecg

WHEN COMPARED WITH ECG OF 26-Feb-2026 08:57,

Premature Ventricular Complexes Are Now Present

T Wave Inversion Now Evident In Inferior Leads

Nonspecific T Wave Abnormality Now Evident In Anterolateral Leads

Impression:

79 y.o. Male with PMHx BPH, frequent UTI, CKD4, Gout, Anemia, Secondary HTN 2/2 Adrenal Adenoma, HLD, Seizures, Depression, OSA, and calcified stable meningiomas, who returned to the ED 1 day after discharge due to altered mental status/aggression. Pt was hospitalized at PYP Hospital 2/21-2/27/26 for UTI and AMS management. Pt was discharged to rehab where he had a new aggressive episode and was subsequently returned to PYP Hospital on 2/28/26. Psychiatry was re-consulted for AMS.

Diagnoses:

Delirium, unspecified cause, Bipolar Disorder, Depression

Recommendations:

Continue Haldol 2 mg IV at bedtime

Continue Haldol 2 mg IV q4H PRN for agitation

Continue Zoloft 50 mg daily

Maintain Mg >2 and K >4

Follow EKG daily and hold standing Haldol if Qtc > 500ms

A sample Psych eval is attached to this assignment