Assessing and Diagnosing Patients With Substance-Related and Addictive Disorders

Complete and submit your Comprehensive Psychiatric Evaluation, including your differential diagnosis and critical-thinking process to formulate primary diagnosis.

Incorporate the following into your responses in the template:

• 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 the patient’s mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses with supporting evidence, listed in order from highest priority to lowest priority. Compare the DSM-5-TR diagnostic criteria for each differential diagnosis and explain what DSM-5-TR criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
• Reflection notes: What would you do differently with this client if you could conduct the session over? Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).
•   Training Title 151
  Name: Daniela Petrov
  Gender: female
  Age:47 years old
  T- 98.8 P- 84 R 20 B/P 132/90 Ht 5’8 Wt 128lbs
  Background: Moved to Everett, Washington from Russia with her parents when she was 16 years
  old. Currently lives in Boise, Idaho. She has younger 1 brother, 3 older sisters. Denied family
  mental health or substance use issues. No history of inpatient detox or rehab denied self-harm hx;
  Menses regular. uses condoms for birth control Has fibromyalgia. She works part time cashier at
  Save A Lot Grocery Store. Dropped out of high school in 10th grade. Sleeps 5-6 hours on