CASE SCENARIO/BACKGROUND: Name: Ms.Fatima Branning. Gender: Female, Age: 28years old.Temp:98.4, pulse: 82. R:18, B/P: 124/74, Ht: 5.0, Wt.118
Background: The patient was raised by her parents, and lives alone in Coronado, CA. The only child works as an administrative assistant in car sales and has a bachelor’s in hospitality. Has a medical history of Scoliosis, Currently treated with Chiropractic care. Guarded and declined to discuss past psychiatric history. Denied family mental health issues and declined to allow you to speak to parents for collaborative information. Allergies: Latex, Menses regular, no birth control.
To Prepare: (1) Consider the insights provided about assessing and diagnosing psychotic disorders. Consider whether experiences of psychosis-related symptoms are always indicative of a diagnosis of schizophrenia. Think about alternative diagnoses for psychosis-related symptoms.
(2) Attached is the Comprehensive Psychiatric Evaluation Template, which you will use to complete this Assignment. Also, review the Comprehensive Psychiatrist Evaluation Exemplar to see an example of a completed evaluation document.
ASSIGNMENT INSTRUCTIONS ARE:
(3) Review the Attached Interview and Case History reports keeping the requirements of the evaluation template in mind.
(4) Consider what history would be necessary to collect from the patient.
(5) Consider what interview questions you would need to ask this patient
(6) Identify at least THREE possible Differential Diagnoses for the patient.
(7) Complete the Comprehensive Psychiatric Evaluation, including the differential diagnoses and critical-thinking process to formulate a Primary diagnosis.
(8) Incorporate the following into your responses in the Template.
(a) Subjective: What details did the patient provide regarding their chief complaints and symptomatology to derive your differential diagnosis? What is the duration and SEVERITY OF their symptoms? How are their symptoms impacting their functioning in life?
(b) OBJECTIVE: What observations did you make during the psychiatric assessment?
(c) ASSESSMENT: Discuss the patient’s mental status examination results. What was your differential diagnosis? Provide a minimum of three possible diagnoses with supporting evidence, listed in order from highest priority to lowest priority.
(d) Compare the DSM-5-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 negatives for the specific case.
(e) 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, health promotion, and disease prevention taking into consideration patient factors, PMH, and other risk factors.
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