For my mid-site evaluation, I presented a case of schizoaffective disorder, bipolar type, along with a detailed discussion of five pharmacologic agents commonly used in psychiatric practice. The case involved a female patient who was initially brought in by EMS for erratic behavior. She presented with grandiosity, paranoia, flight of ideas, and auditory hallucinations. Prior to admission, the patient sustained a subarachnoid hemorrhage at Metropolitan Hospital and was subsequently transferred to Bellevue Hospital for further evaluation. She was later admitted to the inpatient psychiatric unit at Metropolitan Hospital for monitoring and treatment due to concerns for her safety and the safety of others.

During the evaluation, my preceptor emphasized the importance of further investigating the patient’s head injury, as traumatic brain injuries can produce psychiatric symptoms such as hallucinations, delusions, and disorganized behavior – features that were present in this patient. Additionally, my evaluator noted that I should have more thoroughly reviewed laboratory monitoring for lithium therapy, particularly serum levels, to determine whether the medication was within the therapeutic range given the patient’s persistent symptoms of grandiosity and paranoia at the time of my last interview.

For my final site evaluation, I presented a case of borderline personality disorder involving a transgender male patient with a history of multiple suicide attempts, impulsivity, major depressive episodes, and self-harming behaviors. The patient self-presented to the psychiatric emergency department with suicidal ideation and a plan to either jump off a roof or overdose on his prescribed Depakote. He endorsed worsening depressive and anxiety symptoms and reported a history of an unstable and abusive domestic environment. Given the severity of his suicidal ideation, prior attempts, and ongoing psychosocial stressors, he was admitted to the inpatient psychiatric unit for further evaluation and management.

During this evaluation, my preceptor highlighted the importance of thoroughly exploring the patient’s gender identity and social history when diagnosing borderline personality disorder. Patients with this condition often experience instability not only in their relationships with others but also in their sense of self, which can contribute to impulsive and self-injurious behaviors, as seen in this patient.

In my final evaluation, I incorporated laboratory monitoring of the patient’s Depakote levels to assess whether he was within the therapeutic range. It was notable that his valproic acid level increased from 21.2 earlier in January to 116.0 by the end of the month. Nonadherence was suspected, as the patient may have been spitting out his tablets. Consequently, his medication was changed to a liquid formulation, resulting in improved therapeutic levels. This case reinforced the importance of monitoring medication levels in psychiatric patients to determine whether dosage adjustments, medication changes, or adjunctive therapies are warranted when symptoms persist.

At the same time, this experience emphasized that psychiatric treatment should not be guided solely by laboratory values, but rather by a combination of clinical presentation, patient history, and sound clinical judgment. Overall, these site evaluations significantly influenced my clinical reasoning and approach to psychiatric care. Unlike many other medical specialties, psychiatric diagnoses often exist within diagnostic gray areas, with overlapping criteria that can make diagnosis challenging. Nonetheless, these evaluations were valuable in streghening my clinical thinking and reinforcing a more nuanced approach to treating psychiatric conditions.