Psychotherapy

 Comprehensive Psychiatric Evaluation

 For this Assignment, you will document information about a patient that you examined during the last 3 weeks, using the Comprehensive Psychiatric Evaluation Template provided. You will then use this note to develop and record a case presentation for this patient. Be sure to incorporate any feedback you received on your Week 3 and Week 6 case presentations into this final presentation for the course.   

 Required reading and Resources
 https://doi-org.ezp.waldenulibrary.org/10.1176/appi.books.9780890425596.dsm16
 https://edu.meditrek.com/Default.html
  Carlat, D. J. (2017). The psychiatric interview (4th ed.). Wolters Kluwer. 
 Chapter 26, “Assessing Alcohol Use Disorder”   Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan and Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry (11th ed.). Wolters Kluwer.
  Chapter 20, “Substance Use and Addictive Disorders”  
 Chapter 31, “Child Psychiatry”  Section 31.16, “Adolescent Substance Abuse”   
https://academicguides.waldenu.edu/fieldexperience/son/formsanddocuments
 https://academicguides.waldenu.edu/fieldexperience/son/formsanddocuments
 https://academicguides.waldenu.edu/StudentPracticum/NP_StudentOrientation 

  Include at least five (5) scholarly resources to support your assessment and diagnostic reasoning. 
 Subjective: What details did the patient provide regarding their personal and medical history? What are their symptoms of concern? How long have they been experiencing them, and what is the severity? How are their symptoms impacting their functioning? 
 Objective: What observations did you make during the interview and review of systems?  
 Assessment: What were your differential diagnoses? Provide a minimum of three (3) possible diagnoses. List them from highest to lowest priority. What was your primary diagnosis, and why?  
 Reflection notes: What would you do differently in a similar patient evaluation?  
  Diagnosis: Schizoaffective / Bipolar Disorder / Generalized Anxiety Disorder  

Student Notes:Pt is a 26 year old male who stays with the mum. Mum said pt screams at her all the time and gets violent most times which makes living in the house to be hell for her. Pt complained that they stole his money. He said they promised to pay him $10,000 if he lose weight. He lost about  30lbs and they have only given him  $3,000. They are owing him. He has being going to his therapist but he feels that his schizo medications is making him sick so he dose not want to take it anymore. Pt said he wants to take only his Bipolar medicine. Mum said pt has been getting more paranoid and has been having frequent schizoaffective episodes of which he needs to take his medication. Pt wants to go back to Venezuala where the dad owes some houses and live in one of the houses. He said that cost of living is cheaper over there. He also had some issues with his refill because of his ID. The paper work for that will be handled and sent in. Pt’s medications are Olanzapine 30 mg, Trilepto 600 mg AM and 900 mg PM, Haldol 20 mg. Next appointment is in a month’s time.    
 

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