Subjective:

CC: "I am sad every day because my girlfriend left me and went to live in Las Vegas because she feels I drink a lot."

HPI: The patient, S.E., is a 45-year-old Caucasian male who presented in the office for a continued evaluation. He is seen bi-weekly for Alcohol Dependence and Adjustment Disorder. He was married for 20 years, and his wife immigrated, then divorced because his wife was abusing pills and he was using alcohol; his wife went to jail, and the patient got custody of their four kids. The wife returned home, finished rehab, regained custody of the kids, and divorced her husband due to continued use of alcohol. Still, the patient moved to Las Vegas with a friend for work and met his ex-girlfriend. The patient and girlfriend moved to Ohio for the patient's new job. S.E. states he is feeling sad and constantly feeling down, has decreased appetite and anhedonia (feeling no pleasure), and has not slept as much since his girlfriend left him almost a year ago to return to Vegas. When asked what happened over a year ago, he states he moved back to Ohio for a job as an Electrician. Still, he started drinking more than usual and hanging out with friends until the relationship became unhealthy because the patient drank daily. He also states his other symptoms: he feels hopeless because his life is out of control due to alcohol. He once loved to go out and socialize with others, and he still loves a woman moving on without him; he reports he talks and texts with her daily, but it's hard to listen when she speaks about the new relationship she has in her life, she's willing to rebuild with him because she loves him as long as the patient starts making healthier decisions. The pt was observed to be very tearful and emotional during the session. The patient stated he sometimes worries about being a good role model to his 20-year-old, who lives with him. The patient states he still has shared parenting of his kids and doesn't want them to feel he is a failure; when he gets to thinking about his ex and trying to improve, he drinks because it soothes him. So this is a source of concern because E.S. drinks daily.

Mental Status Examination: The patient is a 50-year-old Caucasian male who looks to be his stated age. His attitude is calm and cooperative with the evaluation. The patient is well-groomed, clean, and dressed appropriately for the weather. There is no evidence of any abnormal motor activity. The patient's speech is clear, regular rate, volume, and tone. His thought process is ruminating. There is no evidence of looseness of association or flight of ideas. His mood is tearful, and his affect is appropriate to his mood. E.S. is cognitively alert and oriented to person, place, and time. His recent and remote memory is intact, and his concentration is good. His insight is good. The patient was tearful at times in an appropriate manner and denies any auditory or visual hallucinationsno evidence of delusional thoughts. The patient denies any suicidal or homicidal ideation thoughts.

Must have an introduction and conclusion

• Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What was the duration and severity of their symptoms? How are their symptoms impacting their functioning in life?
• Objective: What observations did you make during the psychiatric assessment?
• Assessment: Discuss the patient's mental status examination results. 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:Describeyour treatment modality and your plan for psychotherapy. Explainthe principles of psychotherapy that underline your chosen treatment plan to support your rationale for the chosen psychotherapy framework. What wereyourfollow-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 HealthyPeople 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 onehealth promotion activity and one patient education considerations for this patient for improving health disparities and inequities in the realm of psychiatry and mental health? Demonstrate your critical thinking.

Please include citations and references so I may follow up for further research. References can not be over five years old.

I appreciate any help you can provide.