DIAGNOSING PATIENTS WITH MOOD DISORDERS
Training Title 2
Name: Ms. Natalie Crew
Gender: Female
Age:17 years old
T 97.4 P–82 R–1 20 128/84 Ht 5’2” Wt 192lbs
Background: Recently started an accelerated high school business program in Chicago, Illinois after growing up and living in New Orleans her whole life. Grew up with both parents and four brothers. Currently lives in a specialty high school campus dormitory. Currently a full–time student and works part-time in the local coffee shop. Not married, currently single. She has no previous psychiatric history; and takes no medications. There is a history of depression, denied a substance use history for her or family. No legal hx NKDA
Complete and submit your Comprehensive Psychiatric Evaluation, including your differential diagnosis and critical-thinking process to formulate a primary diagnosis. Incorporate the following into your responses in the template:
DIAGNOSING PATIENTS WITH MOOD DISORDERS
- 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 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.).