Question Answered step-by-step Subjective:Objective:Assessment:Plan:Reflection notes: 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? What observations did you make during the psychiatric 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. 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. What would you do differently with this patient if you could conduct the session again?==========================================================================Subjective:CC (chief complaint): “I have depression and anxiety.”HPI: J.B. is a 21-year-old single Bi-racial male who presents for psychotherapeutic evaluation due to depression and anxiety. The emergency department referred him for follow-up care. Endorses has been dealing with these issues for “a long time” but feels they became worse in the past month. He thinks he has become worse over the past month and endorses lethargy, loss of appetite, hopelessness, anxiety, near panic, and intense sadness. The mood is described as “apathetic.” He supports some distractibility. Endorses has that he does cut himself to relieve stress, and “I used to bite myself a lot on my wrist when I was a kid.”ROS (Review of Systems)Constitutional: NegativeCardiovascular: NegativeNeurological: NegativePsychiatric/Behavioral: Negative except HPIPast Psychiatric History: General Statement: The patient denies seeing a psychiatrist in the past, except for his recent visit to the emergency room. Caregivers (if applicable): N/AHospitalizations: N/AMedication trials: ProzacPsychotherapy or Previous Psychiatric Diagnosis: The patient denies any substance use history for him or his family.Substance Current Use and History: Both parents have alcohol use issues. He denies any illicit substance use in the family. Family Psychiatric/Substance Use History: Psychosocial History: The patient is single, living with his parents and younger brother. He is a full-time employee at a hotel. He is single, and he is not in a relationship at present. He is a student in a community college. He has a friend with which he can confide. He enjoys photography, music, art video game. The patient was born in Germany and grew up in Fayetteville, NC. No legal issues. History of childhood abuse-mental emotional, and physical per dad.Medical History: Current Medications: Fluoxetine (Prozac) 20 mg capsule take daily for seven days and increase to 40 mg daily after that. Allergies: No known allergiesReproductive Hx: noneObjective:Diagnostic results: CBC, CMP, Liver function test, Thyroid panel.Assessment:Mental Status Examination: Patient J.B dressed neat and clean appropriately with the weather. He is alert and oriented memory is intact and age appropriate. He is attentive and oriented to situation, time, place, and person. Speech is clear, has a regular rate, rhythm, and volume, and responds only to questions. The mood is anxious, depressed, sad, and the effect is blunted, fearful, guarded. Perceptions: no evidence of illusion, no evidence of hallucinations. Memory is intact and age appropriate. Attention is easily distracted, fidgety and restless. Differential Diagnoses: Depression: One resulting from the mental evaluation of the patient is a depressive mood that is accompanied by an adjustment disorder (APA, 2020). The patient reports that feeling depressed or sad mood endorses diminished interest or pleasure in activities and endorses changes in sleep and endorses fatigue or loss of energy, endorses suicidal ideation, and endorses symptoms that cause clinical distress or impairment. One of the three possible differential diagnoses is depression disorder (Zhang et al., 2018).Generalized Anxiety: The patient experiences excessive anxiety and worry more days than not and endorses difficulty in controlling worry and endorses restlessness or feeling on edge, and endorses being easily fatigued, and endorses muscle tension, and endorses, sleep disturbances, and endorses anxiety and worry cause distress. Psychological flexibility was significantly correlated with perceived stress, General anxiety, and depression. Multiple regression analyses showed the possible mediation effect of psychological flexibility between perceived stress and general anxiety or depression (Huang et al., 2021).Posttraumatic disorder: A pathological reaction to extreme life events. The trigger is an extraordinary though common adverse life event. The consequence is severe and long-lasting. Expose to actual or threatened death, severe injury, or sexual violence indirectly experiencing the traumatic events and states repeated or extreme exposure to aversive details of the traumatic events (APA, 2020). The patient reports physical and mental abuse from his father and mother growing up. The patient has witnessed domestic violence. The patient reports directly experiencing a traumatic event. Social Anxiety: He endorses fear or anxiety in a social situation where the individual is exposed to scrutiny and sanctions individual worries. His actions will be negatively evaluated and support that social situation. The social problems are avoided or supported with hearing or anxiety and evidence that fear or anxiety s out of proportion to the context, evidence that symptoms are persistent and lasting longer than six months, and evidence that fear or anxiety or avoidance cause significant impairment. Social Anxiety disorder is known by irrational behavior and altitude towards daily activities (Leichsenring & Leweke, 2017).When you are stressed: stop what you are doing and step away from the situation. Take a few deep breaths. Review the case and act on what you want to do. Relaxation is a recreation that people engage in after working or engaging in any other physically or mentally demanding activity. A relaxed person tendency has lower blood pressure, less stress, slow heartbeat and breathing rate, and more confidence in dealing with challenges. Relaxation can be as simple as sleeping longer, reading a book, exercising, or traveling. Relaxation displays a mental state of peace and serenity in which anxiety and stress are absent. Stress is a mental or emotional tension caused by difficult, unfavorable, or potentially dangerous situations (Ruth, 2020). Yanah Kuscianah Kuswa’s research (2021) uses progressive muscle relaxation techniques on schizophrenic patients with anxiety-related problems, and the results show that muscle relaxation interventions reduce patient anxiety levels. After receiving progressive muscle relaxation, the patient’s anxiety decreased by 30.34% on average.Reflections: Several significant issues have been presented in this case. For example, the number of people with different mental disorders is rising. I have learned psychotherapy how to assess a patient’s background. Pt is needed support and coping skills. The trauma history issues with sexuality and history of bullying. An accurate diagnosis is crucial to studying and recognizing factors and stressors (Sadock et al., 2015). The patient will begin outpatient therapy, focusing on coping skills. The ethical and legal aspects should be carefully measured during the patient’s interview. Under the patient’s consent, psychotherapy and medications management is essential. It is necessary to help determine if thoughts are psychotic or suicidal thoughts to ensure to safety of the patient. Case Formulation and Treatment Plan: The patient will begin individual outpatient therapy at this clinic. Initial treatment focused will be coping skills—patient request for Medication Evaluation. A detailed treatment plan will be developed at the next session. Call 911 or ER if acute worsening of symptoms, decompensation, or thoughts of harming self. Mobile Crisis Management provides immediate crisis response 24 hours a day, 7 days a week 1-877-626-1772. Return to clinic in 5 weeks. Patient preferences follow up appointments is preferred morning. He has also been provided with various resources and emergency numbers. The resources include local counselors, emergency contacts, and online resources regarding mental health issues.References APA. (2020). DSM-5. Psychiatry.org. https://www.psychiatry.org/psychiatrists/practice/dsmHuang, C., Xie, J., Owusua, T., Chen, Z., Wang, J., Qin, C., & He, Q. (2021). Is psychological flexibility a mediator between perceived stress and general anxiety or depression among suspected patients of the 2019 coronavirus disease (COVID-19)? Personality and Individual Differences, 183. https://doi.org/10.1016/j.paid.2021.111132Leichsenring, F., & Leweke, F. (2017). Social anxiety disorder. New England Journal of Medicine, 376(23), 2255-2264. https://www.nejm.org/doi/full/10.1056/NEJMcp1614701Ruth, M. (2020). Relaxation. Salem Press Encyclopedia of Health.Sadock, B. J., Sadock, V.A., & Ruiz, P. (2015). Kaplan &Sadock’s synopsis of psychiatry (11th ed.). Wolters Kluwer.Yanah kuscianah kuswa. (2021). Reduction of Anxiety Levels in Schizophrenia Patients Using Progressive Muscle Relaxation. southeast Asia Nursing Research, 3(2), 90-97. https://doi.org/10.26714/seanr.3.2.2021.90-97Zhang, L., Zhang, J., & You, Z. (2018). Switching of the microglial activation phenotype is a possible treatment for depression disorder. Frontiers in cellular neuroscience, 12, 306. https://doi.org/10.3389/fncel.2018.00306==================================================================Please revise and proofreading. Thank you so much. Health Science Science Nursing NURSING PRAC6645 Share QuestionEmailCopy link Comments (0)

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