Psychiatric Evaluation On Major Depressive Disorder Assignment

, ,

Psychiatric Evaluation On Major Depressive Disorder Assignment

Subjective:

CC (chief complaint): The patient is a 45 year-old African American male presenting with complaints of insomnia, depressed mood or “feeling sad all day”, and ‘wanting to just close myself indoors all the time”. He has been having the symptoms for the past one and a half months.

ORDER HERE A PLAGIARISM-FREE PAPER 

HPI: The patient is a 45 year-old African American male who presents for evaluation with the above complaints. He denies a previous history of the presenting symptoms which he says began about 45 days ago. The duration of the symptoms has been constant since they started. He can no longer enjoy some of the activities that he enjoyed previously. The insomnia and the depressed mood are characteristically relentless and becoming worse by the day. The symptoms are aggravated by solitude but a bit relieved when he is with his family. The symptoms are present during the day and at night all through. When asked to rate the severity of his symptoms he gives a score of 6/10.  Psychiatric Evaluation On Major Depressive Disorder Assignment

Past Psychiatric History:

  • General Statement: He has not had any psychiatric conditions before and does not even remember being treated for any mental condition. He is still functional for self but is slowly becoming dysfunctional on the vocational side since he has been missing work lately.
  • Caregivers: He does not require caregivers at the moment as he is still functional for self and can take care of himself.
  • Hospitalizations: He has never been hospitalized for a mental health condition. The ony admission was for a bout of nonalcoholic fatty iver disease or NAFLD.
  • Medication trials: He has never been put on any psychiatric medications.
  • Psychotherapy or Previous Psychiatric Diagnosis: He has never been diagnosed with a psychiatric condition or been on psychotherapy.

Substance Current Use and History: He denies smoking or using other illegal substances such as marijuana or cocaine. He however admits to drinking socially especially over the weekends with friends.

Family Psychiatric/ Substance Use History: There is no significant psychiatric history on his family’s side except for his maternal grandfather who had been treated for depression while still serving in the army. His father is a smoker and a drinker and is still alive. No one else in the family uses any substance.

Psychosocial History: He is a high school teacher at a local school and likes to go to the countryside for nature viewing and also swimming. He has been married for 18 years and  as a daughter. He stays together with his family but the wife is a tracker and this has occasionally brought disagreements at the home. They live in a neighborhood that has all the necessary amenities such as clean drinking water and a service for garbage collection. In the house there is a smoke detector system and a burglar alarm system. When driving he does not use his phone and always wears a seatbelt. Psychiatric Evaluation On Major Depressive Disorder Assignment

Medical History:

  • Current Medications: He has been regularly using over the counter melatonex 3 mg for his sleeplessness.
  • Allergies: He has no known allergies.
  • Reproductive Hx: He describes himself as a heterosexual male and is married with one child.

Review of Systems (ROS)

  • GENERAL: Denies fever, chills, or weight loss. POSITIVE for fatigue.
  • HEENT: Negative for diplopia, photophobia, tinnitus, otorrhea, rhinorrhea, sneezing, difficulty swallowing and sore throat.
  • SKIN: Denies rashes, itching, or eczema.
  • CARDIOVASCULAR: Denies chest pains or chest tightness and edema.
  • RESPIRATORY: Denies shortness of breath and coughing.
  • GASTROINTESTINAL: Denies diarrhea, vomiting, or nausea.
  • GENITOURINARY: Denies frequency of micturition, dysuria, or hesitancy.
  • NEUROLOGICAL: Negative for syncope, dizziness,
  • MUSCULOSKELETAL: Denies joint pains, muscle pain, or back pain.
  • HEMATOLOGIC: Denies a history of clotting or bood disorders.
  • LYMPHATICS: Negative for lymphadenopathy and splenectomy.
  • ENDOCRINOLOGIC: Denies previous hormonal therapy, excessive thirst, excessive drinking of water, cold intolerance, or heat intolerance (2017, Carlat).

Objective:

Vital signs: 140/95 mmHg (normal cuff sitting), 82 b/m, 16 breaths/ min, 98.7°F; BMI 30.5 kg/m2 (obese)

Diagnostic results:

  • Normal WBC count with no leucocytosis noted.
  • CT scan of the head shows no abnormalities.
  • The Beck Depression Inventory II or BDI-II is positive with a score of 25. This means that he has moderate depression. Psychiatric Evaluation On Major Depressive Disorder Assignment

Assessment:

Mental Status Examination: The client is a 45-year-old African-American male who looks attentive and aware of his surroundings, including place, space, person, event, and time. During the examination, he stands normally and is pleasant. His attire is appropriate for the event and the climate. However, eye contact is poor, and there is some evidence of psychomotor retardation. His speech is straightforward, succinct, and to the point. His speech tempo is lagging and his rhythm is monotonous. On the other side, the loudness is low and minimal. He has no distinguishing mannerisms, gestures, or tics. His self-reported mood is “sad,” and his affect is dysphoric. As a result, the two are congruent. He has no hallucinations or delusions and denies having homicidal ideas, though he admits to having suicide ideas. His insight and judgment are intact and he acknowledges that he is sick and needs treatment. The diagnosis is Major depressive disorder (MDD) with the DSM-5 diagnostic code of 296.22. (F32.1).

ORDER NOW

Differential Diagnoses:

  1. Major Depressive Disorder or MDD: 296.22 (F32.1): The diagnosis for this patient is major depressive disorder or MDD. His symptoms are moderate as indicated by the BDI-II score (APA, 2013; Sadock et al., 2015). Since the onset of the manifestations 45 days ago, the symptoms have been present all the time all day and night. They meet the DSM-5 diagnostic criteria for MDD (APA, 2013; Sadock et al., 2015).
  2. Dysthymia or Persistent Depressive Disorder: 300.4 (F34.1): The patient’s second most likely differential diagnosis is dysthymia, also known as persistent depressive disorder (APA, 2013; Sadock et al., 2015). The DSM-5 diagnostic criteria for it include being depressed for most of the day almost all of the time, as well as experiencing two or more specific complaints while depressed. Insomnia, fatigue, low self-esteem, appetite loss, and reduced focus are among the symptoms. Furthermore, another psychological issue does not fully explain the patient’s condition (APA, 2013; Sadock et al., 2015)Psychiatric Evaluation On Major Depressive Disorder Assignment.
  3. Bipolar Disorder: 296.52 (F31.32): The DSM-5 diagnostic criteria for bipolar disorder must be met, which include a period of continuously elevated arousal with specific symptoms. Distractibility, insomnia, and exaggerated self-esteem are among the symptoms. Significant deterioration is caused by a psychological disease that is not the result of a drug addiction or another physical ailment (APA, 2013; Sadock et al., 2015). Bipolar disorder is ranked third in importance because this patient fits some of these requirements but not all of them.

Reflections: And I would have to assess this 45-year-old again, I would follow the same steps I did the first time. Because I met all of the standards when examining the mentally ill patient (Carlat, 2017). I made assured that all bioethics requirements were met when I examined the client. Before his informed consent was obtained, he was informed of every procedure and therapy as required by autonomy. I kept my word, performed my best, and avoided doing anything which would annoy or offend him and breach nonmaleficence. Above everything, I interacted with him with extraordinary cultural awareness, eliminating any inquiries that would be perceived as disrespectful. Diversity exemplifies the ethical concept of justice (Haswell, 2019). I explained the need of going to all therapy sessions to him (Corey, 2017). The patient has a follow up date after four weeks for evaluation of treatment efficacy and response.  Psychiatric Evaluation On Major Depressive Disorder Assignment

Case Formulation and Treatment Plan:

This is a classic case of major depressive disorder and the management will include both pharmacotherapy and psychotherapy as follows:

  1. Sertraline (Zoloft) 100 mg orally every day (Stahl, 2017)
  2. To continue with the melatonex for the insomnia
  • Cognitive behavioral therapy (CBT) for eight weeks (Corey, 2017)
  1. Family therapy together with his wife
  2. Referral to a dietician and a physical therapist for diet and exercise program for weight reduction
  3. Review or follow up in 4 weeks. Psychiatric Evaluation On Major Depressive Disorder Assignment

 

 References

American Psychiatric Association [APA] (2013). Diagnostic and Statistical Manual of Mental Disorders (DSM-5), 5th ed. Author.

Carlat, D.J. (2017). The psychiatric interview, 4th ed. Wolters Kluwer.

Corey, G. (2017). Theory and practice of counselling and psychotherapy, 10th ed. Cengage Learning.

Haswell, N. (2019). The four ethical principles and their application in aesthetic practice. Journal of Aesthetic Nursing, 8(4), 177-179. https://doi.org/10.12968/joan.2019.8.4.177

Sadock, B.J., Sadock, V.A., & Ruiz, P. (2015). Synopsis of psychiatry: Behavioral sciences clinical psychiatry, 11th ed. Wolters Kluwer.

Stahl, S.M. (2017). Stahl’s essential psychopharmacology: Prescriber’s guide, 6th ed. Cambridge University Press. Psychiatric Evaluation On Major Depressive Disorder Assignment

INSTRUCTIONS ON HOW TO USE EXEMPLAR AND TEMPLATE—READ CAREFULLY

If you are struggling with the format or remembering what to include, follow the Comprehensive Psychiatric Evaluation Template AND the Rubric as your guide.  It is also helpful to review the rubric in detail in order not to lose points unnecessarily because you missed something required. Below highlights by category are taken directly from the grading rubric for the assignments. After reviewing full details of the rubric, you can use it as a guide.

In the Subjective section, provide:

  • Chief complaint
  • History of present illness (HPI)
  • Past psychiatric history
  • Medication trials and current medications
  • Psychotherapy or previous psychiatric diagnosis
  • Pertinent substance use, family psychiatric/substance use, social, and medical history
  • Allergies
  • ROS
  • Read rating descriptions to see the grading standards!

In the Objective section, provide:

  • Physical exam documentation of systems pertinent to the chief complaint, HPI, and history
  • Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses.
  • Read rating descriptions to see the grading standards! Psychiatric Evaluation On Major Depressive Disorder Assignment

In the Assessment section, provide:

  • Results of the mental status examination, presented in paragraph form.
  • At least three differentials with supporting evidence. List them from top priority to least priority. Compare the DSM-5 diagnostic criteria for each differential diagnosis and explain what DSM-5 criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
  • Read rating descriptions to see the grading standards!

Reflect on this case. Include what you learned and what you might do differently. Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).

(The comprehensive evaluation is typically the initial new patient evaluation. You will practice writing this type of note in this course. You will be ruling out other mental illnesses so often you will write up what symptoms are present and what symptoms are not present from illnesses to demonstrate you have indeed assessed for all illnesses which could be impacting your patient. For example, anxiety symptoms, depressive symptoms, bipolar symptoms, psychosis symptoms, substance use, etc.) Psychiatric Evaluation On Major Depressive Disorder Assignment

EXEMPLAR BEGINS HERE

CC (chief complaint): A brief statement identifying why the patient is here. This statement is verbatim of the patient’s own words about why they are presenting for assessment. For a patient with dementia or other cognitive deficits, this statement can be obtained from a family member.

HPI: Begin this section with patient’s initials, age, race, gender, purpose of evaluation, current medication, and referral reason. For example:

N.M. is a 34-year-old Asian male who presents for psychotherapeutic evaluation for anxiety. He is currently prescribed sertraline by (?) which he finds ineffective. His PCP referred him for evaluation and treatment.

Or

P.H. is a 16-year-old Hispanic female who presents for psychotherapeutic evaluation for concentration difficulty. She is not currently prescribed psychotropic medications. She is referred by her mental health provider for evaluation and treatment.

Then, this section continues with the symptom analysis for your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Psychiatric Evaluation On Major Depressive Disorder Assignment

Paint a picture of what is wrong with the patient. This section contains the symptoms that is bringing the patient into your office. The symptoms onset, the duration, the frequency, the severity, and the impact. Your description here will guide your differential diagnoses. You are seeking symptoms that may align with many DSM-5 diagnoses, narrowing to what aligns with diagnostic criteria for mental health and substance use disorders. You will complete a psychiatric ROS to rule out other psychiatric illnesses.

Past Psychiatric History: This section documents the patient’s past treatments. Use the mnemonic Go Cha MP. 

General Statement: Typically, this is a statement of the patients first treatment experience. For example: The patient entered treatment at the age of 10 with counseling for depression during her parents’ divorce. OR The patient entered treatment for detox at age 26 after abusing alcohol since age 13. Psychiatric Evaluation On Major Depressive Disorder Assignment

Caregivers are listed if applicable.

Hospitalizations: How many hospitalizations? When and where was last hospitalization? How many detox? How many residential treatments? When and where was last detox/residential treatment? Any history of suicidal or homicidal behaviours? Any history of self-harm behaviours?

Medication trials: What are the previous psychotropic medications the patient has tried and what was their reaction? Effective, Not Effective, Adverse Reaction? Some examples: Haloperidol (dystonic reaction), risperidone (hyperprolactinemia), olanzapine (effective, insurance wouldn’t pay for it)

Psychotherapy or Previous Psychiatric Diagnosis: This section can be completed one of two ways depending on what you want to capture to support the evaluation. First, does the patient know what type? Did they find psychotherapy helpful or not? Why? Second, what are the previous diagnosis for the client noted from previous treatments and other providers. (Or, you could document both.)

Substance Use History: This section contains any history or current use of caffeine, nicotine, illicit substance (including marijuana), and alcohol. Include the daily amount of use and last known use. Include type of use such as inhales, snorts, IV, etc. Include any histories of withdrawal complications from tremors, Delirium Tremens, or seizures Psychiatric Evaluation On Major Depressive Disorder Assignment.

Family Psychiatric/Substance Use History: This section contains any family history of psychiatric illness, substance use illnesses, and family suicides. You may choose to use a genogram to depict this information (be sure to include a reader’s key to your genogram) or write up in narrative form.

Psychosocial History: This section may be lengthy if completing an evaluation for psychotherapy or shorter if completing an evaluation for psychopharmacology.  However, at a minimum, please include:

  • Where patient was born, who raised the patient
  • Number of brothers/sisters (what order is the patient within siblings)
  • Who the patient currently lives with in a home? Are they single, married, divorced, widowed? How many children?
  • Educational Level
  • Hobbies
  • Work History: currently working/profession, disabled, unemployed, retired?
  • Legal history: past hx, any current issues?
  • Trauma history: Any childhood or adult history of trauma?
  • Violence Hx: Concern or issues about safety (personal, home, community, sexual (current & historical)Psychiatric Evaluation On Major Depressive Disorder Assignment

Medical History: This section contains any illnesses, surgeries, include any hx of seizures, head injuries.

Current Medications: Include dosage, frequency, length of time used, and reason for use. Also include OTC or homeopathic products.

Allergies: Include medication, food, and environmental allergies separately. Provide a description of what the allergy is (e.g., angioedema, anaphylaxis). This will help determine a true reaction vs. intolerance.

Reproductive Hx: Menstrual history (date of LMP), Pregnant (yes or no), Nursing/lactating (yes or no), contraceptive use (method used), types of intercourse:  oral, anal, vaginal, other, any sexual concerns

Diagnostic results: Include any labs, X-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines)Psychiatric Evaluation On Major Depressive Disorder Assignment.

Assessment

Mental Status Examination: For the purposes of your courses, this section must be presented in paragraph form and not use of a checklist! This section you will describe the patient’s appearance, attitude, behavior, mood and affect, speech, thought processes, thought content, perceptions (hallucinations, pseudo hallucinations, illusions, etc.), cognition, insight, judgment, and SI/HI. See an example below. You will modify to include the specifics for your patient on the above elements—DO NOT just copy the example. You may use a preceptor’s way of organizing the information if the MSE is in paragraph form.  He is an 8 yo African American male who looks his stated age. He is cooperative with examiner. He is neatly groomed and clean, dressed appropriately. There is no evidence of any abnormal motor activity. His speech is clear, coherent, normal in volume and tone. His thought process is goal directed and logical. There is no evidence of looseness of association or flight of ideas. His mood is euthymic, and his affect appropriate to his mood. He was smiling at times in an appropriate manner. He denies any auditory or visual hallucinations. There is no evidence of any delusional thinking.   He denies any current suicidal or homicidal ideation. Cognitively, he is alert and oriented. His recent and remote memory is intact. His concentration is good. His insight is good.

Differential Diagnoses: You must have at least three differentials with supporting evidence. Explain what rules each differential in or out and justify your primary diagnosis selection. Include pertinent positives and pertinent negatives for the specific patient case.

Also included in this section is the reflection. Reflect on this case and discuss whether or not you agree with your preceptor’s assessment and diagnostic impression of the patient and why or why not. What did you learn from this case? What would you do differently? Psychiatric Evaluation On Major Depressive Disorder Assignment

Also include in your reflection a discussion related to legal/ethical considerations (demonstrating critical thinking beyond confidentiality and consent for treatment!), social determinates of health, health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).

 

Case Formulation and Treatment Plan.

Includes documentation of diagnostic studies that will be obtained, referrals to other health care providers, therapeutic interventions with psychotherapy, education, disposition of the patient, and any planned follow-up visits. Each diagnosis or condition documented in the assessment should be addressed in the plan. The details of the plan should follow an orderly manner.  *see an example below—you will modify to your practice so there may be information excluded/included—what does your preceptor document?

Example:

Initiation of (what form/type) of individual, group, or family psychotherapy and frequency.

Documentation of any resources you provide for patient education or coping/relaxation skills, homework for next appointment.

Client has emergency numbers:  Emergency Services 911, the  Client’s Crisis Line 1-800-_______. Client instructed to go to nearest ER or call 911 if they become actively suicidal and/or homicidal. (only if you or preceptor provided them)Psychiatric Evaluation On Major Depressive Disorder Assignment

Reviewed hospital records/therapist records for collaborative information; Reviewed PCP report (only if actually available)

Time allowed for questions and answers provided. Provided supportive listening. Client appeared to understand discussion. Client is amenable with this plan and agrees to follow treatment regimen as discussed. (This relates to informed consent; you will need to assess their understanding and agreement.)

Follow up with PCP as needed and/or for:Psychiatric Evaluation On Major Depressive Disorder Assignment

Write out what psychotherapy testing or screening ordered/conducted, rationale for ordering

Any other community or provider referrals

Return to clinic:

Continued treatment is medically necessary to address chronic symptoms, improve functioning, and prevent the need for a higher level of care OR if one-time evaluation, say so and any other follow up plans. Psychiatric Evaluation On Major Depressive Disorder Assignment

ORDER TODAY

References (move to begin on next page)

You are required to include at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines which relate to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting.

instructions and template uploaded. I need to be able to do a video presentation from this assignment. It has to be a mood disorder, so major depressive disorder would work if you could make something up. Also, need two other diagnosis it could be that was ruled out. Psychiatric Evaluation On Major Depressive Disorder Assignment