The clinical assessment involves the application of the instruments such as the DSM-V to determine the clinical and psychological needs of a patient. This assessment entails looking at the patient’s stressors, and the impact of such stressors on the patient’s wellbeing. There are various factors which may alter the emotional wellbeing of the patient, and these factors range from the social factors within the patient’s surroundings, and fear or uncertainty.
When examining a patient for psychological issues, a psychologist needs to consider the primary and secondary diagnoses. This is necessary so that they can provide an intervention that comprehensively meets the patients’ physiological and emotional needs (American Psychiatric Association, 2013a). During the assessment, a psychologist may look at aspects of the patient such as their sexual orientation, sleep patterns, and behaviors when in the presence of others. This information can form the basis for the clinical intervention as described in this study.
Patient: The patient’s name is Mr. David Jackson, and he is a 19-year old male, and the only child in his family.
CC: He is concerned about his friends’ reaction if they learn that he is sexually queer. He feels that his friends will isolate him if he shares the details of his sexuality.
HPI: The 19-year old is worried about the possibility of being isolated by his friends if they learn about his sexual preferences, and he feels uncomfortable when his friends talk ill about gays.
The patient states that he has had suicide ideations because he feels he is different. Still, he is worried about his rejection, and this makes him feel like he wants to die (American Psychiatric Association, 2013b). According to the patient, he is sad and he has fear, and he is shocked to learn that he will be acted with the Navy Reserves.
Past Psychiatric History: David denies psychiatric history. The patient is mentally sound considering that he can differentiate between reality and non-real stuff. He denies ever using a drug to treat psychiatric condition.
Substance Current Use and History: The patient denies substance abuse.
Family Psychiatric/Substance Use History: There is no substance and psychiatric history for the patient’s family.
Psychosocial History: There is no history of psychological and psychiatric problems.
Medical History:
History and Present Illness: The results of the clinical assessment shows that the patient’s temperature is 98.8o F, which is within the normal temperature range. The patient’s respiratory rate is normal, and he seems to be having hypertension given his 110/62 blood pressure. He is concerned about rejection, and this is his main stressor. His symptoms began appearing one and half months ago when he learned that he was being enlisted.
History and Current Use of Substance: The patient denies using any behavior-altering substance.
Medication Trials and Current Medications: David’s family does not currently use any substance.
Psychotherapy or psychiatric Diagnosis for the family: David’s family has no history of psychiatric problems.
Allergies: The patient does not have any history of allergy.
ROS:
Physical exam
General: David shows sign of fear and is moody when being interviewed. He speaks coherently and clearly, and he can be head clearly. He seems to respond to the interview questions in an appropriate manner.
Vital Signs: The patient’s temperature is 98.8 and weighs 133 lbs. His height is 5”7. He does not have enough sleep considering that he sleeps for 6.5 hours. His appetite is good, and he has a 110/62 of blood pressure. This shows that his blood pressure is above the normal level.
The results for the psychological assessments, based on the K
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