Comprehensive Clinical Assessment and Treatment Plan for a 35-Year-Old Male with Generalized Anxiety Disorder

 

 

I’m unable to directly access the attachment you mentioned. However, I can guide you on how to structure a clinical write-up for a psychiatric patient with Generalized Anxiety Disorder (GAD) based on the information you provided. Here’s a template you can use:

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**MRU PMHNP Clinical Write-Up**

**Student Name:** [Your Name]
**Write-Up #:** [Write-Up Number]
**Typhon Case #:** [Case Number]
**Semester/Year:** [Semester and Year]
**Course:** [Course Name]

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**Chief Complaint:**
“What brought you here today…?”

**History of Present Illness:**
Mr. X presents with symptoms suggestive of Generalized Anxiety Disorder (GAD), characterized by:

– **Depression Symptoms:** [Describe symptoms, triggers, and fluctuations]
– **Anxiety:** [Frequency, intensity, triggers, and impact]
– **Mood Swings:** [Describe patterns and severity]
– **Anger/Irritability:** [Frequency and behavioral responses]
– **Attention and Focus:** [Difficulties reported]

– **Current Self-Harm/Suicidal/Homicidal Ideations:** [Assessment and safety considerations]
– **Hallucinations/Paranoia:** [Assessment of psychotic symptoms]
– **Sleep Disturbances:** [Patterns of insomnia or hypersomnia]

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**Past Psychiatric History:**
– Onset of mood symptoms
– Previous psychiatric diagnoses and treatments
– Relevant environmental factors contributing to symptoms
– History of psychiatric medications and response

**Family History:**
– Mental health history of parents, siblings, and grandparents if known

**Personal/Social History:**
– Education, marital status, occupation, work history
– Legal history if relevant

**Substance Abuse History:**
– History of illegal drug use and current usage
– Alcohol abuse history, including frequency and impact
– Tobacco or marijuana use

**Medical History:**
– General medical problems
– Previous surgeries or significant medical events

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**Mental Status Examination:**
– **Appearance and Behavior:** [Gait, posture, grooming]
– **Behavior:** [Mannerisms, psychomotor activity]
– **Attitude:** [Cooperative, hostile, evasive]
– **Level of Consciousness and Orientation:** [Orientation questions]
– **Rapport and Speech:** [Quantity, rate, volume, fluency]
– **Affect and Mood:** [Patient’s self-reported mood vs. observed affect]
– **Perception:** [Presence of paranoia, hallucinations]
– **Thought Content:** [Presence of suicidal, homicidal ideation; delusions]
– **Thought Form/Process:** [Logic, coherence, organization]
– **Cognition:** [Cognitive testing if applicable]
– **Insight and Judgment:** [Understanding of illness, decision-making]

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**Medications:**
– **Medical Medications:** [List and dosage]
– **Psychiatric Medications:** [List and dosage, including rationale and patient education]

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**Psychiatric Diagnosis:**
– **Current Diagnosis:** Generalized Anxiety Disorder (GAD)
– **DSM-5 Symptom Criteria:** [Write out relevant DSM-5 criteria for GAD]
– **Matching Symptoms:** [Documented symptoms matching diagnostic criteria]

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**Billing/Coding:**
– **ICD-10 Code:** [Specific ICD-10 code for GAD]
– **Billing Code:** [Relevant billing code]

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**Treatment Plan:**
– **Medication Changes:** [Any adjustments made during the visit]
– **Clinical Impression:** [Summary of current clinical state]
– **Therapy/Support Recommendations:** [Referrals and resources]
– **Next Visit Scheduled:** [Date and purpose]

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Ensure to fill in each section with specific details based on your assessment and interview with the patient. This template provides a comprehensive framework for documenting the clinical assessment and treatment plan for a patient with Generalized Anxiety Disorder. Adjust the format as needed to fit the specific requirements of your course or clinical setting.

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