Psychiatric assessment
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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 their 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: In your assignment, describe your treatment plan using clinical practice guidelines supported by evidence-based practice. Include a discussion on your chosen FDA-approved psychopharmacologic agents and include alternative treatments available and supported by valid research. All treatment choices must have a discussion of your rationale for the choice supported by valid research. What were your follow-up plan and parameters? What referrals would you make or recommend as a result of this treatment session?
In your written plan include all the above as well as include one social determinant of health according to the HealthyPeople 2030 (you will need to research) as applied to this case in the realm of psychiatry and mental health. As a future advanced provider, what are one health promotion activity and one patient education consideration for this patient for improving health disparities and inequities in the realm of psychiatry and mental health? Demonstrate your critical thinking.
Sample Solution
During the psychiatric assessment, I observed that the patient was alert and oriented with their mood seeming to fluctuate between anxiousness and agitation. They had difficulty controlling their emotions at times but managed to maintain appropriate behavior throughout most of the session. The patient reported feeling overwhelmed by situations as well as feelings of guilt which were exacerbated when interacting with other people.
They also mentioned experiencing intrusive thoughts, sleep disturbances, lack of energy and concentration issues which caused them to struggle in doing everyday activities such as attending class or going to work reliably. In terms of duration, they stated that these symptoms had been present for a few months however they noted that it seemed like they had been there longer due to how difficult they found it dealing with certain situations.
In addition, I took note of physical signs such as increased heart rate and faster breathing which occurred when discussing stressors associated with school or work although no other medical complaints were reported during this assessment. Lastly, I evaluated their level functioning by inquiring about current social activities, hobbies and ability complete tasks independently (with minimal assistance if needed). In this regard it became clear that these symptoms have been having a profound impact on their life as many important aspects were neglected due to how overwhelming everything had become.
Overall, this patient presented a variety of psychological symptoms combined with elevated physiological responses both being exacerbated by trying manage daily demands making differential diagnosis quite challenging yet essential in order provide appropriate treatment plan moving forward.
