Assessing and Diagnosing Patients With Anxiety Disorder
Create documentation in the Comprehensive Psychiatric Evaluation Template about the
patient you selected. In the Subjective section, provide: • Chief complaint• History of
present illness (HPI)• Past psychiatric history• Medication trials and current
medications• Psychotherapy or previous psychiatric diagnosis• Pertinent substance use,
family psychiatric/substance use, social, and medical history• Allergies• ROS
In the Objective section, provide:• Physical exam documentation of systems pertinent to
the chief complaint, HPI, and history• Diagnostic results, including any labs, imaging, or
other assessments needed to develop the differential diagnoses.
In the Assessment section, provide:• Results of the mental status examination,
presented in paragraph form.• At least three differentials with supporting evidence. List
them from top priority to least 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.
Reflect on this case. Discuss what you learned and what you might do differently. Also
include in your reflection a discussion related to legal/ethical considerations
(demonstrate critical thinking beyond confidentiality and consent for treatment!), social
determinates of health, 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.).
Provide at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines that
relate to this case to support your diagnostics and differential diagnoses. Be sure they are current (no more
than 5 years old).
Name: Ms. Serenity Jackson
Gender: female
Age: 24years old
T- 97.5 P- 80 R 18 118/74 Ht 5’2 Wt 136lbs
Background: Born and raised in Gainesville, FL with her mother and 4 older brothers;
her
mother has hx of panic disorder, 2 brothers hx of cannabis; father abandoned the family
when she was 3 years old. One brother is in prison for burglary. no previous mental
health treatment, no medications; NKDA; no legal hx; sleeping 9 hrs.; Appetite is good.
She has an associate of arts degree and works for Leaders furniture warehouse. She
has DX of diabetes since age 8. She recalls having great difficulty with her medical
condition (uncontrolled blood sugar, fighting with mother over needle sticks, “kids want
candy, and I was so different because of my diet”). She recalls having a difficult
relationship with her mother who was a nurse and really worked hard to control her
daughter’s diabetes. She is not in a relationship, identifies as lesbian but has not come
out to the family. Only her closest co-workers know She stated, “I don’t see why I would,
they wouldn’t understand, and this is not important right now.”
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