Assessing and diagnosing patients with disruptive, impulse-control,
When completing a psychiatric evaluation, it is important to consider the patient’s chief complaint and symptomatology, as well as the duration and severity of their symptoms and how they are impacting the patient’s functioning in life. It is also important to obtain a thorough psychiatric and medical history, including past psychiatric diagnoses, medication trials, psychotherapy, substance use and family psychiatric and substance use history. A psychosocial history should also be obtained, as well as a review of systems and physical examination if applicable.
In order to formulate a differential diagnosis, it is important to conduct a mental status examination and make objective observations during the psychiatric assessment. At least three possible diagnoses should be provided with supporting evidence, listed in order of priority. DSM-5 diagnostic criteria should be compared for each differential diagnosis, and the critical-thinking process that led to the primary diagnosis should be explained.
Reflection notes should include any changes that would be made in conducting the session, as well as a discussion of legal and ethical considerations, health promotion and disease prevention, patient factors such as age and cultural background, and other risk factors such as socioeconomic status.
Overall, a comprehensive psychiatric evaluation requires careful consideration of the patient’s presenting symptoms and history, as well as a thorough examination and consideration of possible diagnoses. It is important to approach the evaluation with professionalism, empathy, and attention to detail.