Psychiatric notes are a way to reflect on your practicum experiences and connect the experiences to the learning you gain from your weekly Learning Resources. Comprehensive psychiatric evaluation notes, such as the ones required in this practicum course, are often used in clinical settings to document patient care.
For this Assignment, you will document information about a patient that you examined at your practicum site, using the Comprehensive Psychiatric Evaluation Note Template provided. You will then use this note to develop and record a case presentation for this patient.
Required Media (click to expand/reduce)
Classroom Productions. (Producer). (2016).
Impulse and conduct disorders [Video]. Walden University.
Professor Hartung. (2020).
Multisystemic therapy (MST) for at-risk youth and juveniles informational webinar [Video]. YouTube. https://www.youtube.com/watch?v=yHbTEWCDlpE
PATIENT INFORMATION
Subjective:
CC (chief complaint): “I just need a stable relationship. I need to stay sober to help me control my impulses, I feel increase irritability, anger, and verbal outburst.”
HPI: Mr. T.J. is a 65-year-old Caucasian male who was referred by his primary care provider (PCP) for psychotherapeutic evaluation. Patient states that his wife left him two weeks ago due to his constant verbal abuse and rage on every little thing. Mr. T.J. states that he lost his job two month ago after he had verbal confrontation and verbal abuse of a client. He states that he felt depressed and started drinking and taking cocaine which makes him more irritable, angry, and totally out of control. Patient states that he has married three times and this last one was really a nice person that he wanted to spend the rest of his life with.
PATIENT HISTORY:
Mr. T.J. is a 65-year-old Caucasian male who was referred by his primary care provider (PCP) for psychotherapeutic evaluation. Patient has married three times and his wife of his third marriage left her two weeks ago due to his constant verbal abuse and rage on a very little thing. Patient grow up in Cincinnati Ohio with his parent and two siblings. He first started using alcohol and cocaine after high school and he left his parent and move to Oklahoma and currently lives in Pearland Tx. He got a diploma from a community college and was working as a life insurance agent until two months ago. Patient lost his job after he had verbal confrontation and verbal abuse of a client. Patient has been on and off cocaine and alcohol treatment and had stayed sober for nine months until the last incident of substance use. Diagnosed with anxiety and depression at the age of 45 and prescribed with Sertraline 50 mg PO daily. Has been on and off his medication and last taken his medication three months ago. Patient had a 19-yr-old son form his last marriage. Father has history of depression and mother has anxiety disorder; paternal grandfather has hx of impulse control disorder.
THE QUESTION
Assessment:
What were your differential diagnoses? Provide a minimum of three possible diagnoses in order of highest to lowest priority and explain why
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