Comprehensive Psychiatric Evaluation and Patient Case Presentation Include chief complaint; history of present illness; any pertinent past psychiatric, substance use, medical, social, family history

Comprehensive Psychiatric Evaluation and Patient Case Presentation

Include chief complaint; history of present illness; any pertinent past psychiatric, substance use, medical, social, family history; most recent mental status exam; and current psychiatric diagnosis including differentials that were ruled out.

• Report normal diagnostic results as the name of the test and “normal” (rather than specific value). Abnormal results should be reported as a specific value.

Be succinct in your presentation, and do not exceed 8 minutes. Address the following:

• 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?

 

Name: Mr. Harris, Boss

Gender: Male

Age: 40 years old

BP 131/72, P 79, R 18, T 97.4, SPO2 98%RA, Ht 5’5, Wt 160lbs

 

Background: Patient raised by parent, lives alone in Chicago, IL. Single and has no child. Patient is unemployed with no source of income. Denied any past medical history.  Patient has psychiatric history of schizoaffective disorder. Patient was transferred to emergency department via Chicago police department due to bizarre and erratic behavior with homicidal ideations. Patient was aggressive at home; he threatened to kill his mother. Upon assessment patient stated, “they brought me here.” Noted with racing and scattered thoughts. Patient disorganized delusional, paranoid and suspicious of others. Feels watched and followed believing people are out to get him. Endorses a depressed mood for the past several months. Currently rates mood as a 4/10 whereas 10 is feeling his best. Patient has low energy and no motivation. Has diminished interest in specific things. He has detached relationships with family and friends. Verbalizes feelings of guilt and hopelessness. Internally preoccupied and distracted. Has difficulty with focus and concentration. Very liable and easily agitates. Appetite fluctuates. Patient states he has not been sleeping well at night. No drug/food allergies reported. He smokes marijuana daily since he was 17 and drinks beer once awhile. UDS positive for marijuana and alcohol level <10. Patient takes Risperidone 1 mg PO q 12 hrs and Trazadone HCl 50 mg PO daily at bedtime.

 

You can use the below textbook

 

Reference

Sadock, B.J., Sadock, V.A., & Ruiz, P. (2015). Kaplan & Sadock’s synopsis of psychiatry (11^th ed.). Wolters Kluwer.

 

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