Complete and submit your Comprehensive Psychiatric Evaluation, including your di

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Complete and submit your Comprehensive Psychiatric Evaluation, including your differential diagnosis and critical-thinking process to formulate primary diagnosis.
Incorporate the following into your responses in the template:
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 the patient’s mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses with supporting evidence, listed in order from highest priority to lowest priority. Compare the DSM-5-TR diagnostic criteria for each differential diagnosis and explain what DSM-5-TR criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
Reflection notes: What would you do differently with this client if you could conduct the session over? Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).
Case: Mr. K.B is 24y/m
CC: Bipolar type 2, ADD, GAD, PTSD
Subj
HISTORY OF PRESENT ILLNESS: This is a case of a 24 year old Caucasian single male who comes to the clinic today to establish care with this program today. pt. states he has a lot of medications he is taking, and just moved Jackson city to Burlington city and he could not be driving to see the doctor that far and he decided to see the doctor closer. pt. states he is taking meds for bipolar type 2, PTSD, GAD and ADD. pt. reports sometimes he feels depressed and manic but most time he is stable.
pt. describes his mood today as good, eats and sleeps well. pt. denies SI/HI, denies A/V/H. pt. states his future goal is to own a house, get married and start a family and own his own business. strength is being resilient and honest, man of his works and hard worker, down to earth. weaknesses is his mood fluctuates. pt. is alert and oriented X3, presents with a good judgement.
pt. is Suboxone 8mg am and afternoon and 4 mg at bedtime, Wellbutrin XL 300 mg po daily, Zoloft 100mg po daily, Buspar 10 mg bid, ALLERGIES: PCN- Hives CURRENT PSYCH MEDICATIONS: CURRENT NON-PSYCH MEDICATIONS: PAST PSYCHIATRIC HISTORY: pt. reports at age 8, he was saying suicide things and was taken to psych ward. pt. was placed on Zoloft at the age 8. since pt. has been admitted to psychiatric hospitals 13 times, the last time was 3 years. pt. reports 4 suicide attempts, first time was age 16 and the last was 3 years when pt. slashed his hand with a razor. pt. denies being in any car accident, no head injury or loss of consciousness. pt. denies sexual, physical and emotional abuse.
•O/P Psychiatrist/therapists: 0 pt. states he used therapists in the past but did not help. he has no therapists at this time. •Previous diagnosis: ADHD, Bipolar type 2, ADD, GAD •Previous admissions: 4 •Previous suicide attempts: 4 •Past Medication History: SUBSTANCE ABUSE HISTORY: •Tobacco: pt. used smoke cigarettes, last smoked 2 years ago. •ETOH: pt. reports he drinks socially, last time was a couple of weeks ago. pt. started drinking at age 13. •Illicit Drugs: pt. reports he used to use heroin, 3 years clean now. •Rehab Programs: 4. last time was 3 years ago. SOCIAL HISTORY: pt. was born and raised Hamilton, NJ. pt.’s both parents still alive, divorced. pt. has one brother and two sisters. pt. is the first child. pt. is in relationship, states he is attracted to females. pt. has no children. •Living Situation: lives with his grandparents in a single family. •Marital History: single •Children: 0 •Occupation: pt. works in construction company. •Education: high school graduate •Parents: both alive, divorced •Siblings: 3 •Sexual Orientation: heterosexual. •History of Abuse: denies. •Legal: pt. reports he was on drug court a couple of years ago. states his records purged. FAMILY PSYCHIATRIC HISTORY: pt. reports his aunts and uncles from father’s side with mental health issues. pt. denies family history of substance use. PAST MEDICAL HISTORY: pt. denies :..
Obj
Obj
MSE: General: Good eye contact, well groomed, good hygiene, cooperative and friendly. Psychomotor Activity: normal, euthymic,
Plan
aboratory or Medical Tests: Periodic UDS.
2. Medications as detailed below:.
3. Suboxone/Naloxone 8/2 mg po am and afternoon
4. Suboxone/naloxone 4/1 mg po at bedtime
5. Wellbutrin XL 300 mg po daily in am
6. Zoloft 100 mg po daily in am
7. Buspar 10 mg po bid
8. Follow-up Appointment: in 3 weeks.

 

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