Develop a case study presentation based on a clinical patient
Comprehensive Psychiatric Evaluation/assessment documentation
The response clearly, accurately, and thoroughly follows the Comprehensive Psychiatric Evaluation format to document the selected patient case.
this is clinic scenario using
12/9/2022
Patient initial–J.R
A 20-year-old Spanish man presented to the clinic for a follow-up with his mother, reporting that his job search has made him nervous. Considering more tattoos has also made him nervous.
Medication Management:
Risperdal 1 mg by mouth daily for psychosis
Trazodone 50 mg daily at bedtime for depression
Zoloft 25 mg 1 tablet daily for OCD
Diagnosis-
Obsessives-Compulsive Disorder
Schizophrenia
Depressive Disorder
New order was Vistaril 25 mg by mouth daily PRN
The client was educated on how to rest.
Assessment
rubric
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.
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
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