solved CASE STUDY: TD is a 16 years old African American
CASE STUDY: TD is a 16 years old African American female, seen via telehealth for psychiatric evaluation. Patient has been exhibiting symptoms of anxiety and depression over 3 years ago, since when she lost her father. Patient shows less interest in enjoyable activities, more irritated, crying spells, sadness, and lack of sleep. Patient lost interest in school, had to drop out of high school. Per patient guardian who was present during the intake, patient keep having flash back and nightmare of how her father was shot in her presence. Patient denies suicidal or homicide, Patient denied use of illicit substances, denied history of trauma to the head. Denies AH/VH and SI/HI. Patient was started on Sertraline 100mg Q12hrs, Citalopram 10mg QAM, and Trazodone 50mg QHS. Patient was advised to follow up with clinic in 30 days. Patient was informed, if you think you are experiencing psychiatric emergency, including suicidal or homicidal thoughts, plans, or actions, call Baltimore Crisis Response at 410-433-5175 or National Suicide Prevention Hotline at 1-800-273-8255. If unable to reach any of these numbers, call 911 or go to the nearest ER. Subjective: What details did the patient provide regarding their personal and medical history? What are their symptoms of concern? How long have they been experiencing them, and what is the severity? How are their symptoms impacting their functioning?Objective: What observations did you make during the interview and review of systems? Assessment: What were your differential diagnoses? Provide a minimum of three (3) possible diagnoses. List them from highest to lowest priority. What was your primary diagnosis, and why? Reflection notes: What would you do differently in a similar patient evaluation?