Essay Available:
Pages:
3 pages/≈825 words
Sources:
5 Sources
Style:
APA
Subject:
Health, Medicine, Nursing
Type:
Case Study
Language:
English (U.S.)
Document:
MS Word
Date:
Total cost:
$ 14.58
Topic:
Comprehensive Psychiatric Evaluation: Difficulties Sleeping
Case Study Instructions:
CC (chief complaint):
HPI:
Past Psychiatric History:
- General Statement:
- Caregivers (if applicable):
- Hospitalizations:
- Medication trials:
- Psychotherapy or Previous Psychiatric Diagnosis:
Substance Current Use and History:
Family Psychiatric/Substance Use History:
Psychosocial History:
Medical History:
- Current Medications:
- Allergies:
- Reproductive Hx:
ROS:
- GENERAL:
- HEENT:
- SKIN:
- CARDIOVASCULAR:
- RESPIRATORY:
- GASTROINTESTINAL:
- GENITOURINARY:
- NEUROLOGICAL:
- MUSCULOSKELETAL:
- HEMATOLOGIC:
- LYMPHATICS:
- ENDOCRINOLOGIC:
Physical exam: if applicable
Diagnostic results:
Assessment
Mental Status Examination:
Differential Diagnoses:
Reflections:
PRECEPTOR VERFICIATION:
I confirm the patient used for this assignment is a patient that was seen and managed by the student at their Meditrek approved clinical site during this quarter course of learning.
Preceptor signature: ________________________________________________________
Date: ________________________
Case Study Sample Content Preview:
Week (enter week #): (Enter assignment title)
Student Name
University
Psychopathology and Diagnostic Reasoning
Faculty Name
Assignment Due Date CC (chief complaint): AA indicates that his fiancée urged him to report to the clinic because of the recent difficulties sleeping and sleeping with one of his eyes open at all times. HPI: AA is a 31-year-old Caucasian male who presents to the clinic for a psychiatric evaluation for sleeping difficulties. He is currently not taking any psychotropic prescriptions. As a result, his fiancée encouraged him to seek psychiatric evaluation and treatment because of the emerging symptoms. The patient describes that he has been grappling with diverse symptoms that range from nightmares related to his infantryman duties in Iraq when in a deep sleep. He also presents withdrawal signs because he loves isolation to avoid snapping at others in society due to his irritability (Carlat, 2017). The patient cannot concentrate on his job, remains startled by slight motions or noises, and becomes obsessed with finding non-existent threats. A psychiatric review of these symptoms demonstrates that their onset started three years ago when he suffered trauma while on military duty in Iraq. The frequency of their occurrence has increased significantly, considering that they are disrupting his daily routines, including work and sleep. Such severity has diminished his quality of life greatly. Past Psychiatric History:
- General Statement: The patient has no history of past psychiatric treatment before reporting to the facility. As a result, this incident marks his first psychiatric encounter.
- Caregivers (if applicable): Fiancée.
- Hospitalizations: The patient’s information indicates that he has no history of hospitalizations, detox, or residential treatments. AA does not display homicidal or suicidal behaviors and has no record of self-harm tendencies presently or in the past.
- Medication trials: AA has no recorded history of psychotropic medications for AA.
- Psychotherapy or Previous Psychiatric Diagnosis: AA recognizes suffering from trauma while serving in a local marine reserve in Iraq. However, his case does not mention any treatment initiation.
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