Psych eval 2

1. Compose a written comprehensive psychiatric evaluation of a patient you have seen in the clinic
2. 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.
3. Bellow please use this patient, you can make up whatever information is not available

4. PATIENT 3

   CPT Code: 90791 Psychiatric Diagnostic Evaluation
   Primary ICD-10: F43.10Gender: Male
   Age: 29
   Race: Hispanic
   Ethnicity: Hispanic
   Insurance: Commercial PPO
   Reason for Visit: New consult

   Chief Complaint

   I cant stop reliving the accident.

   HPI / Reason for Psychiatry Visit

   29-year-old male presents with intrusive memories, nightmares, avoidance of driving, hypervigilance, and irritability following a serious motor vehicle accident 1 year ago. Reports impaired functioning at work and strained relationship. Denies SI/HI or substance misuse.

   Clinical Note

   Anxious but cooperative. Mood tense. Affect restricted. Thought process linear. Insight fair.

   Social Problems Addressed

   • Safety
   • Interpersonal Relationships
   • Role Change
   • Emotional

   Immunizations

   • Up-to-date: Influenza
   • Missing: COVID booster

   Procedures / Assessments / Interventions

   • PCL-5: 50
   • PHQ-9: 10
   • GAD-7: 14
   • Trauma assessment

   Principal Diagnosis

   • Posttraumatic Stress Disorder F43.10

   Differential Diagnoses

   1. Panic Disorder F41.0 (panic is trauma-linked)
   2. Generalized Anxiety Disorder F41.1 (symptoms cue-dependent)

   Treatment

   Medication:

   • Venlafaxine XR 37.5 mg PO daily
   • Qty: 30 | Refills: 1
   • Education: BP monitoring, delayed onset

   Psychotherapy:

   • Cognitive Processing Therapy (CPT)
   • Rationale: Addresses trauma-related beliefs and reduces avoidance behaviors.

   Follow-Up

   • 4 weeks

   Allergies

   • Naproxen facial swelling

   Vitals

   BP 124/72 | Temp 98.4F | HR 76 | RR 16 | Ht 59 | Wt 178 lb | BMI 26.3

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