wk3 PRAC

WK3 PRAC. Please use the template and see the exemplar.

Case: The client is 16-year-old female with history of cannabis abuse, ADHD, DMDD. Client reports doing well, sleeping and appetite is good. She reports taking her medication as prescribed and denies any side effects from medications. Client report mood is stable with no behavioral concerns. She reports maintaining good grades at school. Current medications are Intuniv 1mg every morning for ADHD, Focalin XR 5mg Po every morning for adhd, Seroquel 100mg qhs for mood. During this encounter, we discussed diagnosis, rationale, risks, benefit and side effects of medications and treatment with parent. Client and parent verbalized understanding and gave consent for medication and treatment.

Expectation.

· Present the full complex case study. Include chief complaint; history of present illness; any pertinent past psychiatric, substance use, medical, social, family history; most recent mental status exam; current psychiatric diagnosis including differentials that were ruled out; and plan for treatment and management.

· Report normal diagnostic results as the name of the test and “normal” (rather than specific value). Abnormal results should be reported as a specific value.

Specifically address the following for the patient, using your SOAP note as a guide:

· 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? 

· Assessment: Discuss their mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses and why you chose them. List them from highest priority to lowest priority. What was your primary diagnosis and why? Describe how your primary diagnosis aligns with DSM-5 diagnostic criteria and supported by the patient’s symptoms.

· Plan: What was your plan for psychotherapy? What was your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan. Also be sure to include at least one health promotion activity and one patient education strategy.

· Reflection notes: What would you do differently with this patient if you could conduct the session again? If you are able to follow up with your patient, explain whether these interventions were successful and why or why not. If you were not able to conduct a follow up, discuss what your next intervention would be.

· At least 3 citations and 3 references.