Comprehensive Assessment of Mood Disorder
To establish an appropriate treatment plan, a complete client evaluation is necessary and may be carried out during the initial sitting (Wheeler, 2014). It's a comprehensive evaluation that takes the client's social, physical, family, and mental background into consideration and will assist the client establish a personal connection. The client's needs and the physician's treatment decisions are determined by a complete assessment (Phillips, Frank, Loftin, & Shepherd, 2017). The primary goal of this article is to present a complete client evaluation that includes differential diagnosis and a treatment plan for a client who has been watched or counseled.
Subjective:
CC: Pt presents to the clinic with complaints PTSD, Low mood and Suicidal thoughts Presenting Problem: K.L a 28 yr. old AAF who presents at the clinic for a psych evaluation. Pt states “everyone keeps telling me that I have PTSD, even Luke says I have it”. Pt has been diagnosed with Depression since the age of 13 or 14 and states she doesn’t remember the medication given to her. However, she stopped medication to enlist in the military.She has been in the military for 5 yrs. and still active. Pt’s depressions worsen when she experiences her menses. Pt states that Luke states she might have PTSD. Pt reported to have daydreams about helping load soldiers’ body bag, “I think about it all the time”. Pt reports not able to stay asleep, “I toss and turn”, “I am unable to concentrate, appetite is decreases and increases, pt. weights go up and down. Pt feels guilty and worthless, stating “I let my family down, my commander down, I am not worth living”
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