Diagnostic And Statistical Manual of Mental Disorders Assignment Essay
Subjective:
CC (chief complaint): The patient reports experiencing auditory hallucinations and delusions for the past month.
HPI: A 32 year old male patient reports hearing voices speaking to them on a daily basis, which often make derogatory comments about the patient. The patient also reports having delusions of being followed and being in danger. The patient states that these experiences have been causing significant distress and impacting their ability to function in daily life. Diagnostic And Statistical Manual of Mental Disorders Assignment Essay
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Past Psychiatric History:
General Statement: The patient has no prior history of psychiatric treatment or diagnosis.
- Caregivers (if applicable): The patient lives alone and has no identified caregivers.
- Hospitalizations: The patient has not been hospitalized for psychiatric reasons in the past.
- Medication trials: The patient has not previously tried any psychiatric medications.
- Psychotherapy or Previous Psychiatric Diagnosis: The patient has not previously received any psychotherapy or been diagnosed with a psychiatric disorder.
Substance Current Use and History: The patient denies any current or past use of illicit substances. The patient reports occasionally drinking alcohol socially, but states that he does not drink excessively.
Family Psychiatric/Substance Use History: The patient reports no history of psychiatric disorders or substance abuse in their family.
Psychosocial History: The patient is a 32-year-old male who is currently unemployed. The patient reports feeling socially isolated and has limited social support. The patient has no significant romantic relationships at this time.
Medical History: The patient reports no significant medical history and is not currently taking any medications. Diagnostic And Statistical Manual of Mental Disorders Assignment Essay
- Current Medications: None
- Allergies: None reported
- Reproductive Hx: Not applicable
ROS:
GENERAL: The patient is alert and oriented. He denies any physical discomfort or pain.
- HEENT: Head: The patient denies experiencing any headaches or migraines. Eyes: The patient denies experiencing any vision problems. Ears: The patient denies experiencing any ear pain or hearing loss. Throat: The patient denies experiencing any enlarged nodes or sore throat.
- SKIN: The patient reports no skin sores, wounds, or lesions.
- CARDIOVASCULAR: The patient denies experiencing any chest tightness, pain, or discomfort.
- RESPIRATORY: The patient denies experiencing any shortness of breath, wheezing, coughing, or difficulty breathing.
- GASTROINTESTINAL: The patient denies experiencing any diarrhea, vomiting, nausea, or stomach pain.
- GENITOURINARY: The patient reports no dysuria, discharge, or pain.
- NEUROLOGICAL: The patient reports no syncope, dizziness, numbness, or tingling.
- MUSCULOSKELETAL: The patient reports no muscle pain, weakness, joint pain, or swelling.
- HEMATOLOGIC: The patient reports no bleeding, anemia, or bruising.
- LYMPHATICS: The patient denies a history of enlarged lymph nodes.
- ENDOCRINOLOGIC: The patient reports no chills, polydipsia, excess sweating, or cold intolerance. Diagnostic And Statistical Manual of Mental Disorders Assignment Essay
Objective:
Physical exam: Not applicable
Diagnostic results: No diagnostic tests have been conducted at this time
Assessment:
- Mental Status Examination: Appearance and behavior: The patient appears disheveled and anxious. Their behavior is appropriate to the situation.
- Mood and affect: The patient reports feeling anxious and paranoid. Their affect is congruent with their reported mood.
- Speech: The patient’s speech is coherent and goal-directed.
- Thought process: The patient’s thought process is logical and organized.
- Thought content: The patient reports auditory hallucinations and delusions.
- Perception: The patient reports experiencing auditory hallucinations and delusions.
- Cognition: The patient’s cognition is within normal limits.
- Insight and judgment: The patient demonstrates poor insight into their symptoms and the impact he are having on their functioning
Differential Diagnoses:
Schizophrenia: The patient’s reported symptoms of auditory hallucinations and delusions are consistent with the DSM-5-TR criteria for schizophrenia. However, the patient’s relatively short duration of symptoms and lack of a prior psychiatric history suggest that this may not be the most likely diagnosis. Diagnostic And Statistical Manual of Mental Disorders Assignment Essay
Mood disorder with psychotic features: The patient’s reported symptoms of anxiety and paranoia may be consistent with a mood disorder such as major depression or bipolar disorder with psychotic features . The patient’s reported history of limited social support and feelings of isolation could also support this diagnosis (APA, 2013). However, the presence of delusions and auditory hallucinations, as well as the absence of a clear trigger or precipitant for the patient’s symptoms, suggest that this diagnosis may not be the most accurate.
Psychotic disorder due to a general medical condition: The presence of psychosis in the absence of a clear psychiatric cause could potentially be due to a medical condition such as a brain tumor or infection (APA, 2013). However, the patient’s lack of reported medical issues and the absence of any physical exam abnormalities make this diagnosis less likely (Loch, 2019).
Reflections:
If I could conduct the session over, I would spend more time exploring the patient’s social and psychosocial history in order to better understand the potential causes and contributing factors for their psychosis. This could include inquiring about any past trauma or stressors, as well as the patient’s living situation and social support system. Additionally, I would ensure that I have obtained a thorough medical history and consider conducting a physical exam or ordering relevant diagnostic tests to rule out any medical conditions that could be contributing to the patient’s psychosis. Diagnostic And Statistical Manual of Mental Disorders Assignment Essay
In terms of legal and ethical considerations, it would be important to obtain the patient’s informed consent for treatment and to maintain confidentiality in accordance with relevant laws and regulations. It would also be important to consider the patient’s cultural and socioeconomic background and to ensure that the treatment plan is culturally sensitive and appropriate (APA, 2020).. In terms of health promotion and disease prevention, I would consider discussing strategies for managing the patient’s symptoms and improving their overall functioning, as well as any potential risks or triggers for exacerbation of their psychosis. This could include addressing the patient’s social isolation and discussing the importance of maintaining a supportive social network, as well as addressing any potential substance abuse or mental health concerns.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596
American Psychiatric Association. (2020). The American Psychiatric Association practice guideline for the treatment of patients with schizophrenia. American Psychiatric Pub. Diagnostic And Statistical Manual of Mental Disorders Assignment Essay
Loch, A. A. (2019). Schizophrenia
Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life?
Objective: What observations did you make during the psychiatric assessment? 
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Assessment: Discuss the patientâ€
s mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses with supporting evidence, listed in order from highest priority to lowest priority. Compare the DSM-5-TR diagnostic criteria for each differential diagnosis and explain what DSM-5-TR criteria rules out the differential diagnosis to find an accurate diagnosis. 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: What would you do differently with this client if you could conduct the session over? Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), 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.). Diagnostic And Statistical Manual of Mental Disorders Assignment Essay