What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosisSubjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What was the duration a...
Subjective: What details did the patient provide regarding their chief complaint and
symptomology to derive your differential diagnosis? What was 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 in order of highest to
lowest priority and explain why you chose them. What was your primary diagnosis and why?
Describe how your primary diagnosis aligns with DSM-5 diagnostic criteria and is supported
by the patient's symptoms.
Plan: What was your plan for psychotherapy (including one health promotion activity and
one patient education strategy)? What was your plan for treatment and management,
including alternative therapies? Include nonpharmacologic treatments, alternative therapies,
and follow-up parameters, as well as a rationale for this treatment and management plan.
Reflection notes: What would you do differently with this patient if you could conduct the
session again?
ANSWER
A comprehensive assessment of the patient's clinical manifestations, is ess to the
development of an effective and appropriate plan of care, in order to promote good patien
outcomes.
Step-by-step explanation
REVIEWED AND REVISED
Subjective:
CHIEF COMPLAINT: The patient verbalized "I have depression and anxiety"
HISTORY OF PRESENT ILLNESS: J.B. is a 21-year-old bi-racial male who has been diagnosed
with depression and anxiety and is seeking psychotherapy consultation. He was referred for
, follow-up care by the emergency department. Endorses has been suffering with these
challenges for "a long time," but they have gotten worse in the last month, according to him.
He believes he has become worse in the last month, citing lethargy, loss of appetite,
despondency, worry, near panic, and profound melancholy as symptoms. He supports some
distractibility and describes the atmosphere as "apathetic." States that he cuts himself to
relieve tension, and that "as a kid, I used to bite myself a lot on my wrist."
ROS (Review of Systems)
Constitutional: No remarkable findings
Cardiovascular: Heart sounds normal, no murmurs or bruits noted
Neurological: No remarkable findings
Psychiatric/Behavioral: Clinical presentation of a depressive disorder requiring further
evaluation
Past Psychiatric History:
General Statement: The patient denies past psychiatric consultation other than
recent visit to the ER.
Caregivers (if applicable): N/A
Hospitalizations: N/A
Medication trials: Prozac
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