Select a group patient for whom you conducted psychotherapy for a mood disorder during the last 4 weeks. Create a Comprehensive Psychiatric Evaluation.
KC is a 60 years old AA female with a history of GAD and MDD, Bipolar Disorder. Patient reports no changes to demographic information. She reports medication dose is sufficient. Patient’s toxicology results 12/13/23 (negative) were reviewed. Patient is on Wellbutrin 150mg daily. She is a widow and lives by herself,
Open ended questions was used to guide patient during the session. She reported, “My vacation was good. First time on a cruise and it was wonderful. Also, I got my car back from repossession. Life is good right now.” The didactic worksheet was used to explore feelings.
The session focused on patient’s behaviors and attitudes associated with love, gratitude, hope, confidence and happiness. Patient reported I experienced all of these emotions while on vacation. Lol.”
Assessment – Patient is alert and oriented x3. Patient was neat with good hygiene and appropriately attired. She was relaxed and cooperative during the session. She was able to
adequately communicate his thoughts and feelings without hesitation. He presented a receptive and hopeful attitude. She appears to be in the action stage of change.
Plan –Patient will continue to meet and focus on treatment goals and discuss any concerns with his treatment process. She will continue to visit clinic as scheduled, take medication as prescribed and abstain from illicit substances.
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