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Posted: April 13th, 2023
The pt. is a 41-year-old male who presents to the clinic for a psychiatric evaluation. The patient reports he was admitted to the hospital 2 months ago and there were changes made to his medications. The pt. reports that he was first diagnosed when he was 17. The pt. reports anxiousness with being in large crowds and he avoids crowds due to conflict. He reports that he has been in treatment during his teen years. The pt. reports irritability, depression, poor judgement, racing thoughts, insomnia, feelings of hopelessness and worthlessness. pt. reports to have flashbacks and intrusive thoughts. The pt. reports that he uses medicinal marijuana for his PTSD and pain. The pt. denies AH/VH. The pt. denies SI/HI.
Medications: Wellbutrin SR 150mg, Olanzapine 10mg, lorazepam 1mg BIDPRN.
Subjective:
CC (chief complaint):
HPI:
Substance Current Use:
Medical History:
• Current Medications:
• Allergies:
• Reproductive Hx:
ROS:
• GENERAL:
• HEENT:
• SKIN:
• CARDIOVASCULAR:
• RESPIRATORY:
• GASTROINTESTINAL:
• GENITOURINARY:
• NEUROLOGICAL:
• MUSCULOSKELETAL:
• HEMATOLOGIC:
• LYMPHATICS:
• ENDOCRINOLOGIC:
Objective:
Diagnostic results:
Assessment:
Mental Status Examination:
Diagnostic Impression:
Reflections:
Case Formulation and Treatment Plan:
Please keep in mind:
• 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?
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• Objective: What observations did you make during the psychiatric assessment?
• Assessment: Discuss patient mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses and why you chose them. List them from highest priority to lowest priority. What was your primary diagnosis, and why? Describe how your primary diagnosis aligns with DSM-5 diagnostic criteria and supported by the patient’s symptoms.
• Plan: What was your plan for psychotherapy? What was your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan. Be sure to include at least one health promotion activity and one patient education strategy.
• Reflection notes: What would you do differently with this patient if you could conduct the session over? If you are able to follow up with your patient, explain whether these interventions were successful and why or why not. If you were not able to conduct a follow up, discuss what your next intervention would be.
• References
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