CASE STUDY
Name: Ms. Jasmine, Gender: female Age:16 years old T- 98.4 P- 79 R 16 116/72 Ht 5’5 Wt 127lbs
Ms. Jasmine is a 16-year-old AA female who comes to the clinic today with her parents and her brother for continued family psychotherapy session for the treatment of schizoaffective disorder (Bipolar Type), Generalized anxiety disorders, Specific Learning Disorder [With impairment in mathematics and reading], mood disorder and Oppositional defiant disorder. She has two younger brothers, one with history of ADHD, the other with history of anxiety. Her mother has anxiety; her father has paranoia schizophrenia.
Patient stated that her triggers increased in the last week because her parents invited her sister`s three rowdy kids for the X-mas holiday. She becomes irritated, when they will not stay quite at home. Secondly, pt reports ending a shot-term relationship recently. Pt reports trying to remove stress from her life. Pt reports “always having to be the one to apologize to her boyfriends and how this makes her feel and how her family views it.
Jasmine has several friends but has not kept in touch with them since the onset of COVID – 19. She has not been showering in the past few weeks. She sleeps 3–4 hrs/night. Pt reported no SI/HI nor AH/VH or safety concerns.
Select a group patient for whom you conducted psychotherapy for a mood disorder during the last 4 weeks (SEE CASE STUDY)
• . Create a Comprehensive Psychiatric Evaluation Note on this patient using the template provided. There is also a completed template provided as an exemplar and guide.
• Include at least five scholarly resources to support your assessment and diagnostic reasoning.
• Include subjective and objective data; assessment from most recent mental status exam; current psychiatric diagnosis including differentials that were ruled out; current psychotherapeutic plan (include one health promotion activity and one patient education strategy you provided); and patient progress toward treatment goals.
• Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What was 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 in order of highest to lowest priority and explain why you chose them. What was your primary diagnosis and why? Describe how your primary diagnosis aligns with DSM-5 diagnostic criteria and is supported by the patient’s symptoms.
• Plan: What was your plan for psychotherapy (including one health promotion activity and one patient education strategy)? What was your plan for treatment and management, including alternative therapies? Include nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.
• Reflection notes: What would you do differently with this patient if you could conduct the session again?