Professor Hartung. (2020). Multisystemic therapy (MST) for at-risk youth and juveniles informational webinar [Video]. YouTube. https://www.youtube.com/watch?v=yHbTEWCDlpE

PATIENT INFORMATION

Subjective:

CC (chief complaint): “I just need a stable relationship. I need to stay sober to help me control my impulses, I feel increase irritability, anger, and verbal outburst.”

HPI: Mr. T.J. is a 65-year-old Caucasian male who was referred by his primary care provider (PCP) for psychotherapeutic evaluation. Patient states that his wife left him two weeks ago due to his constant verbal abuse and rage on every little thing. Mr. T.J. states that he lost his job two month ago after he had verbal confrontation and verbal abuse of a client. He states that he felt depressed and started drinking and taking cocaine which makes him more irritable, angry, and totally out of control. Patient states that he has married three times and this last one was really a nice person that he wanted to spend the rest of his life with.

PATIENT HISTORY:

Mr. T.J. is a 65-year-old Caucasian male who was referred by his primary care provider (PCP) for psychotherapeutic evaluation. Patient has married three times and his wife of his third marriage left her two weeks ago due to his constant verbal abuse and rage on a very little thing. Patient grow up in Cincinnati Ohio with his parent and two siblings. He first started using alcohol and cocaine after high school and he left his parent and move to Oklahoma and currently lives in Pearland Tx. He got a diploma from a community college and was working as a life insurance agent until two months ago. Patient lost his job after he had verbal confrontation and verbal abuse of a client. Patient has been on and off cocaine and alcohol treatment and had stayed sober for nine months until the last incident of substance use. Diagnosed with anxiety and depression at the age of 45 and prescribed with Sertraline 50 mg PO daily. Has been on and off his medication and last taken his medication three months ago. Patient had a 19-yr-old son form his last marriage. Father has history of depression and mother has anxiety disorder; paternal grandfather has hx of impulse control disorder.

THE QUESTION

Assessment: 

What were your differential diagnoses? Provide a minimum of three possible diagnoses in order of highest to lowest priority and explain why you chose them. What was your primary diagnosis and why? Describe how your primary diagnosis aligns with DSM-5-TR diagnostic criteria and is supported by the patient’s symptoms. 

Plan: 

Describe your treatment modality and your plan for psychotherapy. Explain the principles of psychotherapy that underline your chosen treatment plan to support your rationale for the chosen psychotherapy framework. What were your follow-up plan and parameters? What referrals would you make or recommend as a result of this psychotherapy session?

Reflection notes: 

What would you do differently in a similar patient evaluation? Reflect on one social determinant of health according to the Healthy People 2030 (you will need to research) as applied to this case in the realm of psychiatry and mental health. As a future advanced provider, what are one health promotion activity and one patient education consideration for this patient for improving health disparities and inequities in the realm of psychiatry and mental health? Demonstrate your critical thinking.

For the differential diagnosis use this:

1. Intermittent explosive disorder (IED)

2. Depressive disorder

3. Substance abuse disorder

4. Generalized anxiety disorder