Compose a written comprehensive psychiatric evaluation of a patient you have seen in the clinic

Reminder: It is important that you complete this assessment using your critical thinking skills. You are expected to synthesize your clinical assessment, formulate a psychiatric diagnosis, and develop a treatment plan independently. It is not acceptable to document “my preceptor made this diagnosis.” An example of the appropriate descriptors of the clinical evaluation is listed below. It is not acceptable to document within normal limits.

Bellow please use this patient, you can make up whatever information is not available

PATIENT 4

CPT Code: 99214 Established Patient Follow-Up
Primary ICD-10: F06.32

Gender: Male
Age: 40
Race: Hispanic
Ethnicity: Hispanic
Insurance: Medicaid
Reason for Visit: Follow-up

Chief Complaint

Ive been irritable since my head injury.

HPI

40-year-old male with mood disorder due to traumatic brain injury reports ongoing irritability, emotional lability, and frustration tolerance issues. No prior psychiatric history before TBI 2 years ago.

Social Problems Addressed

Role Change
Emotional
Interpersonal Relationships
Income/Economic

Immunizations

Up-to-date: Influenza
Missing: COVID booster

Assessments

PHQ-9: 9
Cognitive screening: mild deficits

Principal Diagnosis

Mood Disorder Due to Another Medical Condition F06.32

Differential Diagnoses (Supporting Comments)

Major Depressive Disorder F32.9
Temporal relationship with TBI.
Adjustment Disorder F43.23
Symptoms exceed situational response.

Treatment

Medication:

Citalopram 10 mg PO daily

Psychotherapy:

Supportive Psychotherapy with Cognitive Rehabilitation Focus
Rationale: Assists emotional adjustment after neurologic injury.*

Patient Education

Explained link between TBI and mood changes.
Reviewed medication adherence and behavioral coping strategies.

Follow-Up

46 weeks

Allergies

Penicillin rash

Vitals

BP 126/82 | HR 74 | Temp 98.4 | RR 16 | Ht 510 | Wt 195 lb | BMI 28.0

Requirements: varies

WRITE MY PAPER

Comp Eval 3