During my mid-rotation site evaluation, I presented on a transgender (female to male) patient who had a past psychiatric history of schizoaffective disorder and Hypothyroidism. His arrival to the psych ED was in accordance with the Assisted Outpatient Treatment team protocol since the patient had been non-compliant with taking medications. It was a very interesting case because upon evaluation the patient seemed very logical and organized in his thought process. However, upon contacting collateral I learned that the patient’s “wife and kids” were a mere delusion that had been influencing the patient to wander the streets in search of this supposed family. As a result, the main content of my proposed plan for this patient was to get him restarted on his meds while in CPEP for stabilization purposes and do a workup for any substance related contributions. Based on the feedback I received, my HPI was satisfactory and only required minor adjustments in its organization to more accurately reflect the patient’s progression. Alongside this I presented 5 pharmacology cards on the following drugs: Paliperidone palmitate, Mirtazapine, Escitalopram, Benztropine, & Pimozide.

                  For my final site evaluation I presented on a pleasant elderly patient that presented to the ED stating that she did know why she was brought to the hospital as she had no acute complaints. What made it even more challenging was the fact that she spoke Spanish and required a translator and I also later learned she had Alzheimer’s Dementia. Luckily her daughter was spoke English and revealed to me a long and extensive history. She explained that the patient was very aggressive at home, regularly accuses others of stealing, and is quite manipulative. Furthermore, the reason for her being brought into the hospital was because within the last 24hrs she had become increasingly aggressive and was extremely agitated regarding a “stolen debit card” which the ED staff recovered from her private area. I explained to my site evaluator how this was a surprise to me considering how friendly and approachable she seemed and considering her Alzheimer’s she didn’t to have noticeable cognitive deficits. The main feedback I received regarding this case was that I failed to conduct a mini mental status exam which would’ve solidified my assessment of her cognitive status objectively. Going forward I now recognize the importance of such assessments even in the setting of time constraints and language barriers. I also presented another case on a patient with severe depression who also had a stroke in the past year and had expressed an intent to kill himself. This case was the source of inspiration for my article choice of “Imaging markers of post-stroke Depression and Apathy”. Basically, it was a systematic review and meta-analysis addressing recent advances in the ability to detect predictors of post stroke depression and apathy using imaging methods such as functional MRI and diffusion tensor imaging. Essentially the study concluded that it’s not just the laterality of the lesions but the associated architectural changes, types of lesions, and the brain regions/pathways that play into the development of these complications.

                  Based on the feedback I received throughout my evaluations I plan to prioritize the organization of my HPI to better reflect the progression of events because it makes a huge difference to its clarity to others. I also plan to review the major psychiatric assessment tools and be more diligent to ensure that my examination of a patient is complete. These tools can be used in other settings and can augment my presentation of a patient who I suspect has cognitive deficits. I think the biggest lesson I learned is that first impressions of patient especially in Psychiatry are meant to be just a snapshot in time and its best to be reserved in my assessment until I get the full picture.