Martha 40yrs female with no medication history HX of psychiatric depression On Lexapro

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Martha 40yrs female with no medication history, HX of psychiatric, depression. On Lexapro 20mg daily for 10yrs. On Wellbutrin for worsened anxiety. On Zoloft. Has been seeing therapist for 10 yrs  ago.

Broken heart from recent dating with George last week. Denies smoking, drinking and drug use. 

Having suicidal thoughts with plans but afraid to execute it. unable to keep a job. Out of character, inappropriate at the Doctors clinic, not serious, crying, emotional, lonely not happy at all. Grandiose thinking, psychotic behavior, mood swings. Cannot keep a friend. 

practice assessing and diagnosing personality and paraphilic disorders by analyzing a case study and completing assessment documentation on the patient.

  • Consider what history would be necessary to collect      from this patient.
  • Consider what interview questions you would need to ask      this patient.
  • Identify at least three possible differential diagnoses      for the patient.

Complete 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 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.).

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