Comprehensive Psychiatric Evaluation

Patient Information

The patient is John Smith a 16 years old male. He lives with both parents and two siblings. The patient is accompanied by his mother to the health facility. This was after a referral from their family physician. Diagnostic And Statistical Manual of Mental Disorders Assignment

Chief complaints

He presented with chief complaints of excessive worrying, difficulty controlling worry, and restlessness which have been present for the past six months and his mother reports that they have been impacting his school performance and overall quality of life. He is on Citalopram. He has been prescribed Citalopram for the management of symptoms. Diagnostic And Statistical Manual of Mental Disorders Assignment  Diagnostic And Statistical Manual of Mental Disorders Assignment

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History of Presenting Illness

In his history of present Illness, John reports feeling constantly on edge, headaches, and experiencing physical symptoms such as muscle tension. He reports a decrease in appetite with no significant weight loss. Additionally, he experiences difficulty falling asleep and frequently wakes up early, feeling unable to return to sleep.

The severity is moderate as evidenced by the impact of symptoms on daily functioning and the presence of physical symptoms such as decreased appetite and difficulty sleeping. John has been screened for other psychiatric disorders, including bipolar disorder, to ensure appropriate diagnosis and treatment which has been ruled out based on the absence of manic or hypomanic symptoms. Diagnostic And Statistical Manual of Mental Disorders Assignment

Developmental and Social History

John is a second-year student in high school and reports feeling overwhelmed by academic pressures. He is actively involved in extracurricular activities and is in the school’s basketball team. Family relationships are reported stable, with no history of trauma or drug abuse. They have been educated on the black box warning of antidepressant use such as increased risk of suicidal thoughts and behaviors, and have been emphasized on the importance of close monitoring for potential clinical deterioration, unusual behaviors, and suicidal ideation (Boland et al., 2022). Diagnostic And Statistical Manual of Mental Disorders Assignment

Follow-up and Diagnostic Test

John is scheduled for a two-week follow-up appointment to assess treatment response and potential side effects. He is encouraged to adhere to the treatment plan and contact the clinic if experiences any concerning symptoms (Fiorillo et al., 2016). There are no new diagnostic tests currently indicated, however, John may require further evaluation if symptoms persist or worsen despite treatment.

Mental Status Examination

John is well-groomed, cooperative, anxious and has a restricted affect. He has no delusions or hallucinations, his thought content and process is linear and goal-directed. He has no perceptual disturbances and denies any suicidal or homicidal ideation. Diagnostic And Statistical Manual of Mental Disorders Assignment His orientation, attention, and memory are intact and his abstract reasoning is adequate. His concentration and motivation are impaired due to anxiety and his insight of the severity of symptoms is limited, his judgment appears intact. He is a resilient individual struggling with excessive worry. Diagnostic And Statistical Manual of Mental Disorders Assignment

Differential Diagnoses with Rationale

The following are the possible differential diagnoses with rationale, adjustment disorder with Anxiety, due to recent stressors such as academic pressures, but ruled out as symptoms exceed what is typically seen in adjustment disorders. Social Anxiety Disorder due to John’s reported difficulty in social situations; however, the primary focus of his symptoms is not social interactions. John presents with symptoms consistent with Generalized Anxiety Disorder (GAD) based on the DSM-5 criteria, this is supported by John’s excessive worry, restlessness, physical symptoms, and impaired daily functioning (American Psychiatric Association, 2022). His diagnosis therefore is Generalized Anxiety Disorder (F41.1). Diagnostic And Statistical Manual of Mental Disorders Assignment

Treatment Plan 

Pharmacologically, John should continue with Citalopram at the current dosage. Monitor for potential side effects, especially during the initial weeks of treatment. He should begin cognitive-behavioral therapy (CBT) to address maladaptive thought patterns and coping strategies and skills and relaxation techniques and finally refer him to a therapist specialized in CBT for weekly sessions (Baune, 2021). John and his mother have been educated on the nature of GAD, treatment options, and the importance of medication adherence and follow-up appointments. We have discussed the black box warnings and provided resources for managing anxiety symptoms and potential side effects of medication. Diagnostic And Statistical Manual of Mental Disorders Assignment

Outcome

The goal of treatment is to alleviate symptoms, improve daily functioning, and enhance overall quality of his life (Donald, 2019). Regular monitoring and adjustments to the plan will be made based on clinical progress and response. I have done a comprehensive psychiatric evaluation and documentation adhering to professional standards and guidelines. My information is organized clearly and concisely, providing fully John’s psychiatric condition and treatment plan. I have provided the rationale for the diagnosis and treatment plan using evidence-based practices and patient-centered care. Diagnostic And Statistical Manual of Mental Disorders Assignment