Example Three
Patient Name: John Smith
Age: 42
Gender: Male
Date of Evaluation: 03/13/2023
SUBJECTIVE:
The patient, John Smith, presents with a chief complaint of feeling anxious and depressed for the past few months. He reports feeling “down” and “hopeless” most of the time and has trouble sleeping. He admits to using cocaine and alcohol frequently to cope with his symptoms. He reports experiencing tremors and sweating when he tries to stop using substances. John reports that his symptoms have been interfering with his work and relationships, causing significant distress.
OBJECTIVE:
During the evaluation, John appeared anxious and restless, fidgeting in his seat and avoiding eye contact. He had dilated pupils and slight tremors in his hands. His speech was rapid and pressured, and he exhibited psychomotor agitation.
ASSESSMENT:
Mental Status Examination Results:
- Appearance and behavior: The patient appeared anxious and restless, exhibiting psychomotor agitation.
- Mood and affect: The patient’s mood was depressed and hopeless, and his affect was constricted.
- Thought process: The patient’s thought process was rapid and pressured.
- Thought content: The patient expressed feelings of hopelessness and despair.
- Perception: No evidence of perceptual disturbances.
- Cognition: The patient’s cognitive functioning appeared to be intact, with no evidence of memory impairment or disorientation.
- Insight and judgment: The patient had limited insight into his condition and was reluctant to engage in treatment.
Differential Diagnosis:
- Cocaine Use Disorder: The patient exhibits the following symptoms that meet the criteria for Cocaine Use Disorder according to DSM-5: tolerance, withdrawal, and use of the substance in larger amounts or for a longer period than intended. The patient has been using cocaine frequently to cope with his symptoms, which has resulted in functional impairment.
- Alcohol Use Disorder: The patient exhibits the following symptoms that meet the criteria for Alcohol Use Disorder according to DSM-5: tolerance, withdrawal, and use of the substance in larger amounts or for a longer period than intended. The patient reports using alcohol frequently to cope with his symptoms, which has resulted in functional impairment.
- Major Depressive Disorder: The patient exhibits the following symptoms that meet the criteria for Major Depressive Disorder according to DSM-5: depressed mood, anhedonia, insomnia, feelings of worthlessness or guilt, and thoughts of death or suicide.
Critical Thinking Process:
Based on the patient’s history, symptoms, and observations during the evaluation, the primary diagnosis for John is Cocaine Use Disorder. While he also exhibits symptoms of Alcohol Use Disorder and Major Depressive Disorder, his cocaine use appears to be the primary driver of his functional impairment and overall distress. The patient reports experiencing withdrawal symptoms, including tremors and sweating, when he tries to stop using cocaine. Additionally, his physical examination revealed dilated pupils and slight tremors, which are consistent with cocaine use.
Reflected Notes:
If I could conduct the session over, I would spend more time exploring the patient’s social support system and possible underlying stressors. It is also important to address any legal or ethical considerations related to the patient’s substance use, such as driving under the influence or workplace policies. Health promotion and disease prevention strategies should also be discussed, including harm reduction techniques and referral to substance use treatment programs. Finally, cultural and socioeconomic factors should be considered when developing a treatment plan that is tailored to the patient’s unique needs and circumstances.