By Day 1 of this week, select a specific video case study to use for this Assignment from the Video Case Selections choices in the Learning Resources. View your assigned video case and review the additional data for the case in the “Case History Reports” document, keeping the requirements of the evaluation template in mind. Consider what history would be necessary to collect from this patient. Consider what interview questions you would need to ask this patient. Identify at least three possible differential diagnoses for the patient. Complete and submit your Comprehensive Psychiatric Evaluation, including your differential diagnosis and critical-thinking process to formulate primary diagnosis.

Subjective:

CC (chief complaint): “I fear telling others about my sexuality”

HPI: the patient is Mr. Ralph Newsome, a 19-year-old male that came to the psychiatric clinic for psychiatric assessment. The patient is a former military personnel and currently works part time in construction. The patient reports difficulties in telling others about his sexuality. The patient reports that he has been weighing about the benefits and disadvantages of revealing his sexuality as a gay. He fears the ridicule that he would experience from other soldiers after knowing about his sexuality. The patient reports that he has never told anyone about his sexuality, except the psychiatrist. The patient reports that he fears that others will not be comfortable being around him after he tells them his sexuality. The patient denies sexual thoughts about men but reports interest in close relationship with them as well as women. He also acknowledges fear of rejection from others following his disclosure. He reports suicidal thoughts when he was young but denies any recent thoughts, plans, or intention.

Past Psychiatric History: The patient denied any history of psychiatric illnesses

  • General Statement: I fear telling others about my sexuality
  • Caregivers (if applicable):none
  • Hospitalizations: the client denies any history of hospitalization
  • Medication trials: The client denies any history of medication trials
  • Psychotherapy or Previous Psychiatric Diagnosis: The client denies any history of psychotherapy or previous psychiatric diagnosis

Substance Current Use and History: The client denies any current or previous use of alcohol, smoking, and other substance use or abuse

Family Psychiatric/Substance Use History: The client denies any history of psychiatric or substance abuse history in the family

Psychosocial History: The client lives alone with his dog. He is the only child in his family. He currently works part time in construction. He has been recalled to Iraq to work as a soldier. The patient reports that his family is his source of social support. He denies any stress. However, he fears telling others about his sexuality.

Medical History: The patient denied any history of hospitalization or surgeries.

 

  • Current Medications: The patient is not currently using an medications.
  • Allergies: The patient reported that he is allergic to Penicillin. He denied food and environmental allergies.
  • Reproductive Hx: The patient is single. He is not in a relationship. He denies dysuria, frequency and urgency. He also denies any history of sexually transmitted infections or abuse.

ROS:

GENERAL: The patient is dressed appropriately for the occasion. There is no evidence of weight loss, fever, chills, weakness, or fatigue.

HEENT: Eyes: The patient denies visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: He also denies hearing loss, sneezing, congestion, runny nose, or sore throat.

SKIN: The patient denies rash or itching.

CARDIOVASCULAR: The patient denies chest pain, chest pressure, or chest discomfort. He also denies palpitations or edema.

RESPIRATORY: The patient denies shortness of breath, cough, or sputum.

GASTROINTESTINAL: The patient denies anorexia, nausea, vomiting, or diarrhea. He also denies abdominal pain or blood.

GENITOURINARY: The patient denies burning on urination, urgency, hesitancy, odor, odd color

NEUROLOGICAL: The patient denies headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. He also denies change in bowel or bladder control.

MUSCULOSKELETAL: The patient denies muscle, back pain, joint pain, or stiffness.

HEMATOLOGIC: The patient denies anemia, bleeding, or bruising.

LYMPHATICS: The patient denies enlarged nodes. No history of splenectomy.

ENDOCRINOLOGIC: The patient denies reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.

Objective:

Physical exam:

Vital signs: BP 119/76 P 68 T 36.7 SPO2 98% at room air, RR 20 beats per minute, regular

Respiratory: Presence of clear lung sounds and absence of wheezing, cough, and nasal flaring.

Cardiovascular: Presence of S1 and S2 heart sounds. Absence of adventitious heart sounds and body edema.

Diagnostic results Order this paper