Detail a complete diagnosis, with differential, and treatment plan, including specific medication and the dosing you would recommend. Describe what key topics and themes you would discuss with the patient as part of their informed consent to start or refuse the psychotropic medication you recommend. In your diagnosis, outline your clinical reasoning that led to your conclusion.
Please include pertinent labs, all psychiatric medications needed. This subject is psychiatry
This is a discussion. Do not include Title page, all resources have to be from the United States and from years 2019-2024. THIS IS A DOCTORATE PAPER, not undergraduate.
Robert is a 24-year-old preoperative transgender male. He presents today with a chief complaint of “My anxiety has taken over my life. I can’t do anything without constantly worrying or freaking out about the most mundane things.” He goes on to describe how persistent worry has always been “part of who I am. I’m the worrier in the family.” In the past year, he’s noticed himself becoming more anxious in social settings “regardless of who’s there. I could know everyone and I worry whether I’m being a good friend, guest, or host. If I don’t know most of the people, I’ll usually decline the invite with some lame excuse.” He has frequent moments through the day “where I freak out. Someone cuts me off on the road – pull to the side and freak out for 30 minutes. Someone make a crude joke in class – ruminate over whether they were talking about me for the rest of the day. It’s endless!” He feels constant tension in his back and neck, endorses feeling like he “crashes” at the end of the day from all the energy he puts into worrying, and “nothing shuts it off.”
Current medication from PCP: Testosterone Cypionate 20mg IM QWeek over the next month with plans to increase to 50mg and 100mg within the year as part of his transitioning. Ondansetron 8mg SL PRN Q12h for nausea associated with hormone therapy.
OTC Medications: Melatonin 3-5mg PO QHS PRN for sleep support with efficacy. Magnesium Supplement 600mg PO QD for sleep support with efficacy. Daily multivitamin with iron.
No significant acute or chronic illness is endorsed. No significant family history of mental illness. No significant family history of acute or chronic medical conditions. No history of previous psychiatric medication management. Engaged with a psychotherapist as part of his transitioning care plan.