COMPREHENSIVE PSYCHIATRIC EVALUATION NOTE AND PATIENT CASE PRESENTATION, PART 1
Order Instructions
– Review this week’s Learning Resources and consider the insights they provide about clinical practice guidelines.
– Select a group patient (case > grandmother and 2 granddaughters more details provided below) for whom you conducted psychotherapy for a mood disorder during the last 4 weeks. Create a Comprehensive Psychiatric Evaluation Note on this patient using the template provided in the Learning Resources.
– There is also a completed template provided as an exemplar and guide.
Include at least five scholarly resources to support your assessment and diagnostic reasoning.
CASE Details:
Child #1 – 9-year-old female client was present with her paternal grandmother for a follow-up counseling session. Client reports she is doing well today. She lives with her paternal grandmother and stepsister. Family history of substance use (both parents). Diagnosis: adjustment disorder with anxiety. Client reports she worries about everything. She worries more at night before sleep. She has a fear of being alone. She reports that she sleeps well at night. Denies any nightmares. Client states reading helps with managing her stress. She plans to spend the next 2 months with her biological mother, client states that she is excited to visit her mother. Discussed and demonstrated Butterfly Hug with client to manage anxiety symptoms as needed, client verbalized understanding and was able to demonstrate it. Plan: Continue therapy sessions.
Child #2: 5-year-old female client was present with her paternal grandmother for a follow-up counseling session. Client states she is feeling good, denies any sadness or irritability. Reports that she is doing good at school. History of trauma. Client reports she and her stepsister are getting along pretty well. She is excited to visit her mother this summer and will be staying with her for 2 weeks. The client reports she is sleeping well. Plan: continue therapy to help develop techniques to manage or regulate her emotions (emotional regulation).
Grandmother: Female client presents with her two granddaughters for follow-up psychotherapy sessions. Client reports things are getting better at home. The relationship between her granddaughters is improving, and she is able to manage her stress effectively as well. Plan: continue therapy sessions to help support with managing stress with parenting.
Please combine this family as a group and add more information as needed for the assignment.
Include subjective and objective data; assessment from most recent mental status exam; current psychiatric diagnosis including differentials that were ruled out; current psychotherapeutic plan (include one health promotion activity and one patient education strategy you provided); and patient progress toward treatment goals.
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-TR diagnostic criteria and is supported by the patient’s symptoms.
Plan: Describe your treatment modality and your plan for psychotherapy. Explain the principles of psychotherapy that underline your chosen treatment plan to support your rationale for the chosen psychotherapy framework. What were your follow-up plan and parameters? What referrals would you make or recommend as a result of this psychotherapy session?
Reflection notes: What would you do differently in a similar patient evaluation? Reflect on 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.
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