Psychiatric Diagnostic Evaluation for Adult is to be submitted as a written paper (with title page and references per APA) Please follow the 2 pages rubric and the sample GUIDE page I provided. It should be with 8 to 9 references.
Include in your assessment a work-up and/or questions for adult-specific disorders. What diagnostic tests/screening tools would you use for the adult?
Include in your assessment a genogram – a minimum of 3 generations back from the patient and if
they have children or grandchildren then also going forward. Watch for patterns.
Include in your treatment plan specific types of therapy that are used when working with adults
with the diagnosis, you have chosen.
Address in your narrative how family structure and dynamics affect the diagnosis and treatment
of your patient. What are the family dynamics for this patient and how does it affect the mental
status of this patient.
What developmental stage should the patient be in based on chronological age and is the patient
in that stage?
Address parenting styles that you observed with your patient and the family and whether these
were working or not working.
How does the family culture affect the diagnosis and treatment plan for this patient?
How did the patient’s family of origin impact this patient and the way the patient has adapted to
work, school, and current family life?
How do the patient’s diagnosis impact this patient and the way the patient has adapted to work,
school and current family life?
What is this patient’s biggest stressor and how can the patient be taught to deal with it in a
healthier manner?
what to cover below (sub headings0Have to cover these?
Psychiatric Diagnostic Evaluation for Adult
Identifying Data: 30 years old Hispanic American male, single with no child, mentally disabled, and unemployed.
Summary:
Background:
Case presentation:
Demographics:
Source and Reliability:
Chief Complaint:
History of present illness:
Current Medications: Olanzapine 15 mg, 1 tablet orally once a day, Sertraline 50 mg, 1 tablet orally once a day, Clonazepam 0.5mg, 1 tablet at bedtime orally once a day, Montelukast (Singulair) 10mg tablet po daily, Albuterol inhaler 1- 2 inhalations every 4 to 6 hours.
Past Psychiatric History:
Past Psychiatric Medication: Olanzapine 10 mg tablet, 1 tablet orally at bedtime
Substance Use/Abuse:
Medical History:
Allergies:
Family History
Developmental / Social History
Mental Status Exam
Assets and Liabilities:
Physical Examination
Diagnostic Tests
Case Formulation Section
Differential Diagnoses
Other psychiatric illnesses
Anatomic lesions
DSM 5 Diagnosis with ICD 10 Code
Paranoid Schizophrenia – F20.0 (primary)
Schizoid personality disorder – F60.1
Moderate intellectual disability – F71
Treatment Plan
Pharmacology:
Labs:
Evidence-Based non-pharmacological intervention
Patient & Family Education:
Referrals:
Psychotherapy Treatment Plan
Medication adherence therapy (MAT):
Family intervention therapy (FI):
Outcome and Follow-Up:
Discussion:
Student Signature and Date
Learning Points
Strengths and Deficits of Write Up
Genogram
References-5
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