Conduct a Comprehensive Psychiatric Evaluation on this patient using the template provided in the Learning Resources. There is also a completed exemplar document in the Learning Resources so that you can see an example of the types of information a completed evaluation document should contain. All psychiatric evaluations must be signed by your Preceptor. You will submit your document in Week 5 Assignment, Part 2 area and you will include the complete Comprehensive Psychiatric Evaluation as well as have your preceptor sign the completed assignment. You must submit your documents using Turnitin. Please Note: Electronic signatures are not accepted. If both files are not received by the due date, Faculty will deduct points per the Walden Late Policies.
· Develop a video case presentation, based on your progress note of this patient, that includes 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.
Full Answer Section
Chief Complaint: "I've been feeling really anxious and on edge lately. I can't seem to relax and I'm having trouble sleeping."
History of Present Illness:
The patient is a 32-year-old male who presents with complaints of anxiety and insomnia. He reports feeling increasingly anxious and irritable over the past few months. He describes his anxiety as a constant sense of unease and worry, accompanied by difficulty concentrating, restlessness, and irritability. He reports experiencing frequent episodes of feeling overwhelmed and panicky. He describes difficulty falling asleep and staying asleep. He wakes up frequently throughout the night and often feels fatigued throughout the day. He denies any recent stressful life events, but reports increased work demands and family responsibilities.
Past Psychiatric History:
- No prior history of psychiatric treatment.
- No history of suicide attempts or self-harm.
Past Medical History:
- Type 2 Diabetes mellitus
- Hypertension
- No known allergies.
Substance Use History:
- Denies current use of alcohol or illicit drugs.
- Reports occasional social use of alcohol (1-2 drinks per week).
- No history of substance abuse or dependence.
Family Psychiatric History:
- Mother: History of depression
- Father: History of anxiety disorder
- No known family history of bipolar disorder, schizophrenia, or psychosis.
Social History:
- Lives with wife and two young children.
- Employed full-time as a [Insert Occupation].
- Reports good social support from family and friends.
- Denies any legal or financial problems.
Mental Status Examination:
- Appearance: Appears stated age. Dress and grooming are appropriate for the setting.
- Behavior: Cooperative and attentive during the interview. No evidence of psychomotor agitation or retardation.
- Speech: Normal rate, rhythm, and volume.
- Mood: Appears anxious and irritable.
- Affect: Restricted range of affect.
- Thought Process: Linear and logical. No evidence of flight of ideas, pressured speech, or thought blocking.
- Thought Content: Denies suicidal ideation or homicidal ideation. No evidence of delusions, hallucinations, or obsessions.
- Cognition: Alert and oriented to person, place, and time. Attention and concentration intact. Memory intact for recent and remote events.
- Insight and Judgment: Fair insight into current difficulties. Judgment appears intact.
Assessment:
- Primary Diagnosis: Generalized Anxiety Disorder (GAD)
- Differential Diagnoses:
- Major Depressive Disorder: While anxiety is prominent, there is no evidence of depressed mood, anhedonia, or significant changes in appetite or sleep.
- Social Anxiety Disorder: While social anxiety may be a contributing factor, the patient's anxiety appears to be more generalized and pervasive.
- Substance/Medication-Induced Anxiety Disorder: While possible, there is no current evidence to suggest that any medications or substances are contributing to his anxiety.
Recommendations:
- Psychotherapy: Cognitive-behavioral therapy (CBT) is recommended as a first-line treatment for GAD.
- Pharmacotherapy: Consider initiating pharmacotherapy with an SSRI or SNRI antidepressant, such as sertraline or escitalopram.
- Psychoeducation: Educate the patient about GAD, including symptoms, treatment options, and stress management techniques.
- Lifestyle modifications: Encourage regular exercise, relaxation techniques (e.g., deep breathing, mindfulness), and stress management strategies.
- Regular follow-up: Schedule regular follow-up appointments to monitor symptoms, adjust treatment as needed, and address any concerns.
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Preceptor Signature: _____________________________________
Date: _____________________________________