Comprehensive Psychiatric Evaluation Note and Patient Case Presentation
Group therapy: DG is a 17 years old African American male. He is a member of the skills development group. DG also suffer from alcohol addiction. He stated that he started drinking alcohol since 12 years of age, but he became a heavy drinker at 15 years of age. He stated that is heavy drinking is a result of been depressed. He stated that he didnâ€t grow up the way he thinks kids should. He stated he is from a poor family who suffers from everything. He stated that he started school at the age of 6 years of age but was bullied throughout his elementary school days due to his poor appearance to school. He said he felt devasted and doesnâ€t want to go to school at some point. He stated that his mother will ensure he walks through the school door because she turns around. DG mentioned that he had engaged in so many bad things in school in other to get expelled from school, but he was only suspended twice. DG mentioned that he feels depressed about life because he doesnâ€t seem to live his fair to him and family. The treatment plan for this group is for the clients to learn healthier ways of living and how to develop a healthier relationship. They will be able to diagnose the causes of their problems and come up with appropriate methods to solve them.
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.
Present the full complex case study. Be succinct in your presentation, and do not exceed 8 minutes. 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 patientâ€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 patientâ€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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