UO Psychiatric Diagnostic Evaluation for Adolescent Worksheet
Include in your assessment a work-up and/or questions for adolescent-specific disorders. What
diagnostic tests/screening tools would you use for the adolescent?
Include in your treatment plan specific types of therapy that are used when working with
adolescent.
Address in your narrative how family structure and dynamics affect the diagnosis and treatment
of this adolescent. What are the family dynamics for this patient and how does it affect the
mental status of this adolescent.
What developmental stage should the patient be in based on chronological age and is the patient
in that stage?
Address parenting styles that you observed with your patient and the family and whether these
were working or not working.
What is the ethical considerations when working with teens – how much do you share with the
parents, do you have the parents in the room with you the whole time you are talking to the
patient, who do you talk to first when they come in with a problem? What happens when they
leave the nest?
what to cover below (sub headings0Have to cover these?
Psychiatric Diagnostic Evaluation for Adolescent
Author / Source of Case Presentation:
Identifying Data:
Summary
Background
Case Presentation
Demographics
Source and Reliability
Chief Complaint
History of Present Illness
Psychiatric Review of Systems
Current Symptoms
Current Medication / Treatment
Past Psychiatric Medication &History
Substance Abuse Assessment:
Past Medical History
Family Psychiatric and Substance History
Family Psychiatric and Substance History
Developmental / Social History
Mental Status Exam
Physical Examination
Diagnostic Tests
Case Formulation Section
Differential Diagnoses
Formulation: Justification for Diagnosis
DSM 5 Diagnosis with ICD 10 Code
Treatment Plan
Student Signature and Date
Learning Points
Strengths and Deficits of Write Up
15 y/o single, Caucasian male in 10th grade in high school. The patient wants to kill himself because his father does not allow him to visit his mother who lives separate from them after both parents separated.
