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psych case

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07.10.2026
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InstructionsforCasePresentation.docx
PatientCaseforPresentation.docx
GradingRubricForPsychCasePresentation.pdf

InstructionsforCasePresentation.docx

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 instructor’s 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.

4. Prior to your scheduled presentation date, submit your Power Point into the appropriate assignment folder and onto the discussion board for instructor/class review.

5. Class participation and attendance is expected to every scheduled case study. Instructors will provide an allotted time between each presentation for group discussion. If you cannot attend a presentation, you are expected to notify and obtain approval by your instructor, prior to the scheduled date of the missed presentation, and an alternate assignment will be required.

PatientCaseforPresentation.docx

9/28/26

Demographics: 34-year-old female, married, employed full-time.

Visit Type: 60-minute initial psychiatric evaluation via secure telemedicine.

Reason for Visit: Evaluation of worsening anxiety, depression, insomnia, and impaired daily functioning.

Chief Complaint: “I feel overwhelmed all the time, and I’m not sleeping well.”

Psychiatric Diagnoses:

· Major depressive disorder, recurrent, moderate (F33.1)

· Generalized anxiety disorder (F41.1)

· Insomnia disorder (F51.04)

Medical Comorbidities: Hypertension and hypothyroidism.

Current Medications: Levothyroxine 75 mcg daily; Amlodipine 5 mg daily. No current psychiatric medications.

Social Problems: Work stress, marital strain, financial concerns, and limited time for self-care.

Procedures: Comprehensive psychiatric assessment, MSE, depression/anxiety assessment, sleep assessment, medication reconciliation, substance-use screening, and suicide risk assessment.

Clinical Note: Patient reports persistent sadness, excessive worry, fatigue, poor concentration, decreased interest, and difficulty initiating sleep. Symptoms have worsened over the past several months and are affecting work and home functioning. Denies mania, psychosis, substance misuse, SI, or HI.

S: Reports depressed mood, anxiety, insomnia, low motivation, and poor concentration.

O: A&O ×4, cooperative. Mood depressed/anxious; affect congruent. Thought process linear. No psychosis.

A: MDD and GAD with insomnia and functional impairment.

P: Start escitalopram 5 mg daily for 1 week, then increase to 10 mg daily as tolerated. Encourage psychotherapy, sleep hygiene, and stress-management strategies. Monitor mood, anxiety, sleep, and medication tolerability. Follow up in 2–4 weeks.

New Medication: Escitalopram 5 mg daily → 10 mg daily.

Activity Time: 60 minutes Complexity: High CPT: 90792 ICD-10-CM: F33.1, F41.1, F51.04

Has a child, 2 siblings

Social: No smoking, social drinker

Family Hx includes identified relational status with current or historical psych illness, treatments, responses, suicides, or self-harm- None

Vitals- 148/88, HR- 82,T – 97.6, Lungs clear

Allergies: PCN

Surgeries: Appendectomy

InstructionsforCasePresentation.docx

Instructions

Case Study Presentations

Format and Expectations for Case Study Presentations:

2. The client presented in the case study presentation cannot be any other client you presented in any other assignment.

4. Prior to your scheduled presentation date, submit your Power Point into the appropriate assignment folder and onto the discussion board for instructor/class review.

PatientCaseforPresentation.docx

9/28/26

Demographics: 34-year-old female, married, employed full-time.

Visit Type: 60-minute initial psychiatric evaluation via secure telemedicine.

Reason for Visit: Evaluation of worsening anxiety, depression, insomnia, and impaired daily functioning.

Chief Complaint: “I feel overwhelmed all the time, and I’m not sleeping well.”

Psychiatric Diagnoses:

· Major depressive disorder, recurrent, moderate (F33.1)

· Generalized anxiety disorder (F41.1)

· Insomnia disorder (F51.04)

Medical Comorbidities: Hypertension and hypothyroidism.

Current Medications: Levothyroxine 75 mcg daily; Amlodipine 5 mg daily. No current psychiatric medications.

Social Problems: Work stress, marital strain, financial concerns, and limited time for self-care.

Procedures: Comprehensive psychiatric assessment, MSE, depression/anxiety assessment, sleep assessment, medication reconciliation, substance-use screening, and suicide risk assessment.

S: Reports depressed mood, anxiety, insomnia, low motivation, and poor concentration.

O: A&O ×4, cooperative. Mood depressed/anxious; affect congruent. Thought process linear. No psychosis.

A: MDD and GAD with insomnia and functional impairment.

New Medication: Escitalopram 5 mg daily → 10 mg daily.

Activity Time: 60 minutes Complexity: High CPT: 90792 ICD-10-CM: F33.1, F41.1, F51.04

Has a child, 2 siblings

Social: No smoking, social drinker

Family Hx includes identified relational status with current or historical psych illness, treatments, responses, suicides, or self-harm- None

Vitals- 148/88, HR- 82,T – 97.6, Lungs clear

Allergies: PCN

Surgeries: Appendectomy

InstructionsforCasePresentation.docx

Instructions

Case Study Presentations

Format and Expectations for Case Study Presentations:

2. The client presented in the case study presentation cannot be any other client you presented in any other assignment.

4. Prior to your scheduled presentation date, submit your Power Point into the appropriate assignment folder and onto the discussion board for instructor/class review.

PatientCaseforPresentation.docx

9/28/26

Demographics: 34-year-old female, married, employed full-time.

Visit Type: 60-minute initial psychiatric evaluation via secure telemedicine.

Reason for Visit: Evaluation of worsening anxiety, depression, insomnia, and impaired daily functioning.

Chief Complaint: “I feel overwhelmed all the time, and I’m not sleeping well.”

Psychiatric Diagnoses:

· Major depressive disorder, recurrent, moderate (F33.1)

· Generalized anxiety disorder (F41.1)

· Insomnia disorder (F51.04)

Medical Comorbidities: Hypertension and hypothyroidism.

Current Medications: Levothyroxine 75 mcg daily; Amlodipine 5 mg daily. No current psychiatric medications.

Social Problems: Work stress, marital strain, financial concerns, and limited time for self-care.

Procedures: Comprehensive psychiatric assessment, MSE, depression/anxiety assessment, sleep assessment, medication reconciliation, substance-use screening, and suicide risk assessment.

S: Reports depressed mood, anxiety, insomnia, low motivation, and poor concentration.

O: A&O ×4, cooperative. Mood depressed/anxious; affect congruent. Thought process linear. No psychosis.

A: MDD and GAD with insomnia and functional impairment.

New Medication: Escitalopram 5 mg daily → 10 mg daily.

Activity Time: 60 minutes Complexity: High CPT: 90792 ICD-10-CM: F33.1, F41.1, F51.04

Has a child, 2 siblings

Social: No smoking, social drinker

Family Hx includes identified relational status with current or historical psych illness, treatments, responses, suicides, or self-harm- None

Vitals- 148/88, HR- 82,T – 97.6, Lungs clear

Allergies: PCN

Surgeries: Appendectomy

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