Subjective:
CC (chief complaint):
HPI:
Past Psychiatric History:
• General Statement:
• Caregivers (if applicable):
• Hospitalizations:
• Medication trials:
• Psychotherapy or Previous Psychiatric Diagnosis:
Substance Current Use and History:
Family Psychiatric/Substance Use History:
Psychosocial History:
Medical History:
• Current Medications:
• Allergies:
• Reproductive Hx:
ROS:
• GENERAL:
• HEENT:
• SKIN:
• CARDIOVASCULAR:
• RESPIRATORY:
• GASTROINTESTINAL:
• GENITOURINARY:
• NEUROLOGICAL:
• MUSCULOSKELETAL:
• HEMATOLOGIC:
• LYMPHATICS:
• ENDOCRINOLOGIC:
Objective:
Physical exam: if applicable
Diagnostic results:
Assessment:
Mental Status Examination:
Differential Diagnoses:
Reflections:
References
Complete and submit your Comprehensive Psychiatric Evaluation, including your differential diagnosis and critical-thinking process to formulate a primary diagnosis. Incorporate the following into your responses in the template:
• Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life?
• Objective: What observations did you make during the psychiatric assessment?
• Assessment: Discuss the patient’s mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses with supporting evidence, listed in order from highest priority to lowest priority. Compare the DSM-5-TR diagnostic criteria for each differential diagnosis and explain what DSM-5 criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
• Reflection notes: What would you do differently with this client if you could conduct the session over? Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).
CASE STUDY
Name: Mr. Elijah Loman
Gender: male
Age:18 years old
T- 98.3 P- 93 R 22 118/68 Ht 5’7 Wt 149lbs
Background: Currently lives with his sister and two parents in Durham, NC. Not currently employed. Completed high school, not currently in school. Hx of treatment for mood disorder began age 15, previous trials of risperidone, quetiapine off and on, side effects of wt. gain. Has hx of a six-day hospitalization one year ago after found wandering at night in the mall parking
lot without clothes. He refused medication due to previous experiences. Not currently partnered.
He has been sexually inappropriate with comments to female neighbors; pulled his pants down in
the mall. Denies any recent alcohol or substance use. Father has history of bipolar disorder. No history of self-harm behaviors, no family suicides. Mother reports he has slept 4-5 hours in past week, up spending money buying and playing new video games and says he is writing a book on
how others can be a video game master. Appetite is decreased. No medical hx; Hx of vandalism as a juvenile. Has pending court date for indecent exposure. Allergies: latex
PLACE THIS ORDER OR A SIMILAR ORDER WITH NURSING TERM PAPERS TODAY AND GET AN AMAZING DISCOUNT
