Martha 40yrs female with no medication history, HX of psychiatric, depression. O
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Martha 40yrs female with no medication history, HX of psychiatric, depression. On Lexapro 20mg daily for 10yrs. On Wellbutrin for worsened anxiety. On Zoloft. Has been seeing therapist for 10 yrs ago.
Broken heart from recent dating with George last week. Denies smoking, drinking and drug use.
Having suicidal thoughts with plans but afraid to execute it. unable to keep a job. Out of character, inappropriate at the Doctors clinic, not serious, crying, emotional, lonely not happy at all. Grandiose thinking, psychotic behavior, mood swings. Cannot keep a friend.
practice assessing and diagnosing personality and paraphilic disorders by analyzing a case study and completing assessment documentation on the patient.
Consider what history would be necessary to collect from this patient.
Consider what interview questions you would need to ask this patient.
Identify at least three possible differential diagnoses for the patient.
Complete Comprehensive Psychiatric Evaluation, including your differential diagnosis and critical-thinking process to formulate 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 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.).