Comprehensive Psych Note on Major Depressive Disorder Essay

Comprehensive Psychiatric Evaluation

Demographics & Identifying Data

Patient: S.D.

Age: 14 years

Gender: Female

Accompanied by: Parents

Referral Source: Referred by primary care physician

Summary

Fourteen-year-old patient presents with symptoms that are typical of Major Depressive Disorder (MDD). Her school performance and social functioning are impacted by her feelings of sadness, hopelessness, exhaustion, poor appetite, and difficulties sleeping. There was no mention of any significant medical history, drug abuse, or family history of mental illness (Kaser & Sahakian, 2019). Her parents who accompanied her to the health facility were worried about her recent behavioral changes. Comprehensive Psych Note on Major Depressive Disorder Essay

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Background

This case study and its psychiatric evaluation is vital because depression has a major influence on adolescent functioning and requires immediate and appropriate management to avoid long-term implications. If left untreated, S. D’s symptoms may result in drastic academic decline, social disengagement, and an increased risk of suicide. Documenting her case and developing a complete treatment plan can help improve her prognosis and general well-being.

Case Presentation

S.D lives with her parents and younger brother in a suburban neighborhood. Both parents are working professionals. S.D is a 9th-grade student at a local public high school and has been struggling academically. She presents with symptoms of depression, including sadness, fatigue, decreased appetite, and sleep disturbances. No history of substance uses or significant medical conditions reported. Comprehensive Psych Note on Major Depressive Disorder Essay

S.D. resides in a suburban neighborhood together with her parents and younger brother. Both parents are employed in their respective professional field. S.D. is a local public high school student in her ninth grade who has been having academic difficulties. She shows depressive symptoms, such as sadness, exhaustion, appetite loss, and sleep difficulties. There was no record of substance abuse or serious medical issues.

Chief Complaint

Parents report concerns about S. D’s mood changes, isolation, academic decline, and physical symptoms.

History of Present Illness

The patient reports feeling sad, hopeless, and worthless most of the time. She experiences fatigue, decreased appetite, and difficulty sleeping. Symptoms have been present for several months and are worsening. Comprehensive Psych Note on Major Depressive Disorder Essay

Current Medications

None

Past Psychiatric History

No history of psychiatric disorders reported.

Past Psychiatric Medications

Not Applicable

Substance Use/Abuse

Denies any substance use or abuse.

Medical History

No significant medical history reported.

Allergies

No known food and drug allergies.

Family History

No family history of mental health disorders reported.

Psychiatric and Addiction History

None reported.

Developmental and Social History

She is a good student but has been struggling academically recently. She has a few close friends but has been withdrawing from social activities. Comprehensive Psych Note on Major Depressive Disorder Essay

Mental Status Exam (MSE)

Appearance and Behavior: The adolescent appears withdrawn and avoids eye contact.

Motor Activity: Exhibits psychomotor retardation.

Speech: Soft spoken.

Mood: Depressed.

Affect: Blunted.

Thought Content: Reports recurrent thoughts of death but denies any active suicidal ideation.

Thought Process: Sequential and logical.

Perceptual Disturbances: None reported.

Cognition: Intact.

Abstract Reasoning: Impaired.

Concentration: Difficulty concentrating.

Impulsivity: Denies impulsivity.

Insight: Limited insight into illness.

Judgment: Impaired judgment. Comprehensive Psych Note on Major Depressive Disorder Essay

Threat to Self or Others: Denies suicidal ideation.

Motivation: Low motivation.

Strengths and Weaknesses:

Strengths: Good family support, insight into symptoms.

Weaknesses: Academic decline, social withdrawal.

Diagnostic Tests

None indicated at this time.

Case Formulation

She presents with symptoms consistent with Major Depressive Disorder (MDD), characterized by depressed mood, anhedonia, fatigue, appetite and weight changes, sleep disturbances, psychomotor agitation or retardation, feelings of worthlessness or guilt, difficulty concentrating, and recurrent thoughts of death (Black et al., 2014). Comprehensive Psych Note on Major Depressive Disorder Essay

Differential Diagnosis

Adjustment Disorder with Depressed Mood (F43.21)

This disease presents by the emergence of emotional or behavioral symptoms in response to a specific stressor within three months of its onset. In this situation, stressors such as academic pressures and social issues may cause symptoms of depression, weariness, and decreased appetite. However, her symptoms appear to be more pervasive and severe beyond what would be expected for an adjustment disorder

Dysthymic Disorder (F34.1) Comprehensive Psych Note on Major Depressive Disorder Essay

This condition, also known as persistent depressive disorder, is characterized by a chronic, low-grade depressive mood that lasts for at least a year in teenagers, with episodes of severe symptoms. While S. D’s symptoms have been present for several months, they appear to have become more severe recently, indicating an abrupt onset rather than a chronic, continuous pattern. Sarah’s symptoms also fulfill the criteria for a MDD, rather than the milder, chronic presentation associated with dysrhythmic disorder.

Major Depressive Disorder, single episode (F32.0)

This diagnosis best fits the patient’s presentation. MDD is characterized by the presence of a major depressive episode lasting for at least two weeks, involving symptoms such as depressed mood, anhedonia, sleep disturbances, changes in appetite or weight, fatigue, psychomotor agitation or retardation, feelings of worthlessness or guilt, difficulty concentrating, and recurrent thoughts of death (Flaherty & Horowitz, 2016). Her symptoms align closely with the criteria for MDD, and there is no evidence of a chronic or persistent pattern indicative of dysthymic disorder. Furthermore, Sarah’s symptoms are not solely attributable to an identifiable stressor, as required for the diagnosis of adjustment disorder. Therefore, MDD is the most appropriate diagnosis for Sarah’s current presentation. Comprehensive Psych Note on Major Depressive Disorder Essay

Diagnosis

Major Depressive Disorder, single episode (F32.0)

Treatment Plan

Pharmacology: Considering the severity of the patient’s symptoms, Initiate fluoxetine 10mg daily, with close monitoring for potential side effects including gastrointestinal upset, headache, and insomnia.

Psychotherapy: Refer her to a licensed therapist specializing in adolescent mental health for cognitive-behavioral therapy (CBT) to address negative thought patterns, improve coping skills, and enhance problem-solving abilities (Abdijadid, 2020).

Referrals: Recommend family therapy to educate parents about MDD and improve family communication and support. Comprehensive Psych Note on Major Depressive Disorder Essay

Patient Education: Educate S.D and her parents about depression, treatment options, and the importance of medication adherence and therapy attendance.

School Support: Collaboration with the school counselor and teachers will be established to develop an academic accommodation plan, including extensions on assignments, reduced workload, and provision of additional support services as needed.

Outcome and Follow-up

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S.D will be scheduled for regular follow-up appointments to monitor treatment response, assess for side effects, and make necessary adjustments to the treatment plan. Comprehensive Psych Note on Major Depressive Disorder Essay

References

Abdijadid, S. (2020). Major Depressive Disorder and Management. National Center for Biotechnology Information. https://www.ncbi.nlm.nih.gov

Black, D. W., & Jon E. Grant, M. (2014). DSM-5 guidebook: The essential companion to the diagnostic and statistical manual of mental disorders (5th ed.). American Psychiatric Pub.

Flaherty, L. T., & Horowitz, H. (2016). Adolescent psychiatry, v. 21: Annals of the American Society for adolescent psychiatry. Routledge.

Kaser, M., & Sahakian, B. J. (2019). Major depressive disorder as a disorder of cognition. Cognitive Dimensions of Major Depressive Disorder, 23-34. https://doi.org/10.1093/med/9780198810940.003.0003

Comprehensive Psychiatric Evaluation

Submit a comprehensive psychiatric evaluation on a child or adolescent with a mental illness. Give a short synopsis of the case and why the patient has come to see you.

Source of Information

Identifying data – Do not include any real identifying data or location.

Summary (Up to 150 words summarizing the case presentation and outcome.)
Background (Why do you think this case is important-why did you decide to write it up?)
Case Presentation (Presenting features, medical/social/family history.)

Demographics should include: age, sex, who they live with, who they are accompanied by for your interview, who referred them to you. Comprehensive Psych Note on Major Depressive Disorder Essay
Chief Complaint of Patient:
History of Present Illness
Current Medications
Past Psychiatric History
Past Psychiatric Medications
Substance Use/Abuse
Medical History
Allergies
Family History
Psychiatric and Addiction History
Developmental and Social History
MSE: Appearance and behavior
Motor activity
Speech
Mood
Affect
Thought content (sensorium) Comprehensive Psych Note on Major Depressive Disorder Essay
Thought process
Perceptual disturbances
Cognition
Abstract Reasoning
Concentration
Impulsivity
Insight
Judgment
Threat to self or others
Motivation
Strength and Weakness

Diagnostic Tests
Case Formulation

Differential Diagnosis (with rationale)

Diagnosis (Include ICD 10 codes)

Treatment Plan:

Pharmacology
Psychotherapy
Referrals
Patient Education Comprehensive Psych Note on Major Depressive Disorder Essay

Outcome and Follow-up

Complete and submit an outstanding comprehensive psych note from an actual patient you cared for in your practicum experience.

Please do a comprehensive on a child age 14 with DX of major depression

Please make sure the Treatment is appropriate and the case formulation is there. follow the rubric exactly and mention side effects of the treatment. Be very thorough. Comprehensive Psych Note on Major Depressive Disorder Essay