IDENTIFICATION:

The patient is a 24-year-old, single, Asian-American female. CHIEF COMPLAINT:

“PAST PSYCHIATRIC HISTORY:

No previous psychiatric treatment or medications. No history of suicide attempts or assaultive behavior. MEDICAL HISTORY: Takes birth control pills. No operations. No medical conditions. Feels tired for the past month. Having difficulty getting to sleep and staying asleep. HISTORY OF DRUG OR ALCOHOL ABUSE: Denied. FAMILY HISTORY: Raised by both Korean-born parents with a younger sister. Father has a history of anemia. No psychiatric family history. PERSONAL HISTORY Perinatal: Full-term vaginal birth. Childhood: Started biting her fingers. Started playing in school orchestra. Adolescence: Had many friends. Participated in a number of school organizations.

Adulthood: Graduate student in music education for the past two months. Unemployed. Had worked in retail sales. Identifies as a Methodist. Has the same boyfriend for the past two years. No military service or legal history. TRAUMA/ABUSE HISTORY: Denied. MENTAL STATUS EXAMINATION Appearance: Well groomed. Fingers are visibly scarred above the proximal interphalangeal joint. Behavior and psychomotor activity: Good eye contact. No motor abnormalities. Cooperative. Consciousness: Alert but appears tired. Orientation: Oriented to all three spheres. Memory: Grossly intact.

Concentration and attention: Reports difficulty concentrating. Pacing at night and unable to focus on her school requirements. Was generally attentive and focused during the interview. Visuospatial ability: Not assessed. Abstract thought: Not assessed formally but seems satisfactory. Intellectual functioning: Average or above. Speech and language: Normal rate and volume. Perceptions: No altered perceptions. Thought processes: Organized and logical.

Thought content: Preoccupied with academic demands. Suicidality and homicidality: Denied. Mood: Anxious. Affect: Full range. Mood congruent. Impulse control: Good other than not being able to control biting her fingers. Judgment/Insight/Reliability: Good. Title Page

Introduction

What screening tools (if any) or laboratory tests (if any) would you use to further evaluate this patient?

What are your differential diagnoses for this patient? Include DMS-5 TR codes and ICD-10 codes Include rationale for ruling in or ruling out the diagnoses. What diagnosis would you rule in as your working diagnosis?

What pharmacological interventions would you include, if any?

Include the rationale for the medication(s), if prescribed. Include any monitoring and titration if indicated. What are the goals of the treatment?

What psychotherapeutic interventions would you complete that day, and what type of psychotherapy might you refer to a therapist? Include the rationale for the types of therapy.

What are the goals of therapy? What complementary and alternative medicine treatments might you recommend for this patient?

Include the rationale for your recommendations. What are the goals of the treatments? What patient education would you provide for this patient? Include: Medications Follow up Referrals Psychoeducation What cultural and ethical considerations would you consider with this patient? Summary References

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