One assignment, a psychiatric evaluation, is worth 10% of this course grade. Students will be expected to select one of the patients in the clinical site without using any identifiable demographics and write a psychiatric evaluation of the client and case formulation following the criteria below.
Assessment: Documents all required assessment findings of a psychiatric evaluation following standardized criteria
Diagnosis: Determines DSM5 diagnosis based on criteria and supported by symptomatology presented
Treatment Plan: Recommend a plan of care following a standardized format, fully documented
Case Formulation: Documents comprehensive review of biopsychosocial aspects of the client, including expected outcomes
example :
Thomas Deliver, a 36-year-old male, presents with complaints of difficulties with concentration, completing tasks, and maintaining attention in various settings, including work and home. He reports significant impairment in his ability to organize tasks, meet commitments, and manage his responsibilities as a father.
Mr. Deliver describes longstanding challenges with attention and focus, which have intensified following his recent divorce. He attributes these difficulties to problems with communication and organization that contributed to the breakdown of his marriage. He reports symptoms such as chronic lateness, trouble initiating and completing tasks, and forgetfulness.
Mr. Deliver’s medical history includes hypertension, for which he takes hydrochlorothiazide (HCTZ), and hyperlipidemia managed with fish oil supplementation. He has a history of asthma but has not required the use of a rescue inhaler for several years. He takes a daily men’s multivitamin.
There is no reported history of psychiatric diagnoses or treatment. Mr. Deliver has expressed concerns about the stigma associated with psychiatric diagnoses and hesitancy regarding the use of psychotropic medications.
Family history is notable for possible ADHD symptoms in Mr. Deliver’s immediate family members, including a sibling who was diagnosed with ADHD during childhood.
Mr. Deliver is a computer programmer by profession. He recently finalized his divorce and has joint custody of his two daughters, ages 6 and 10. He reports challenges in maintaining a regular schedule and managing his children’s extracurricular activities. He expresses worry that his difficulties with attention and organization may impact his custody arrangement and job stability.
There is no reported history of substance use or abuse. The patient’s appearance is casual, appropriate for the setting. His behavior is cooperative during the interview, maintains eye contact. Normal rate and tone, coherent speech. He is anxious regarding the impact of his symptoms on his life. His affect is full range and appropriate. Logical and goal-directed thought process is observed. No delusions or hallucinations. His cognition is intact, oriented to time, place, and person. No evidence of cognitive impairment. Limited insight into the impact of ADHD symptoms on his life; judgment appears intact.
Based on the assessment findings and symptomatology described, Mr. Thomas Deliver meets the criteria for Attention-Deficit/Hyperactivity Disorder, Predominantly Inattentive Presentation (314.00). Symptoms include persistent difficulties with attention to details, organization, and completing tasks, consistent with the DSM-5 criteria for ADHD.
Initiate treatment with stimulant medication, specifically methylphenidate (e.g., Ritalin), to target ADHD symptoms. Start with a low dose and titrate based on response and tolerability.
Provide Mr. Deliver and his family with education about ADHD, including its symptoms, course, and treatment options. Address concerns about stigma and the benefits of treatment.
Refer Mr. Deliver for cognitive-behavioral therapy (CBT) to develop strategies for improving organization, time management, and coping skills. Schedule regular follow-up appointments to monitor medication response, assess for side effects, and adjust treatment as needed. Collaborate with Mr. Deliver’s employer and family to evaluate improvements in functioning.
Mr. Thomas Deliver presents with significant impairment in attention and organizational skills, impacting his professional and personal life. Biopsychosocial factors contributing to his presentation include genetic predisposition (family history of ADHD), recent life stressors (divorce), and medical comorbidities (hypertension). Psychosocial stressors include challenges in parenting and maintaining daily routines.
With comprehensive treatment addressing pharmacological, psychoeducational, and behavioral interventions, expected outcomes for Mr. Deliver include improved attention, organization, and time management skills. Enhanced coping strategies and reduced functional impairment should contribute to improved job performance, better familial relationships, and increased overall quality of life.
In conclusion, this psychiatric evaluation and case formulation provide a structured approach to understanding Mr. Deliver’s ADHD symptoms, integrating clinical findings, diagnosis, treatment plan, and expected outcomes. Adjustments may be made based on ongoing assessment and collaboration with Mr. Deliver and his support network.