What is the duration and severity of their symptoms?
Ø How are their symptoms impacting their functioning in life?
Objective:
Ø What observations did you make during the psychiatric assessment?
Assessment:
Ø Discuss the patient’s mental status examination results.
Ø What were your differential diagnoses?
Ø Provide a minimum of three possible diagnoses with supporting evidence, listed in order from highest priority to lowest priority.
Ø Compare the DSM-5-TR diagnostic criteria for each differential diagnosis and explain what DSM-5-TR criteria rule out the differential diagnosis to find an accurate diagnosis.
Ø Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
Reflection notes:
Ø What would you do differently with this client if you could conduct the session over?
Ø Include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!).
Ø Also include health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).