Assessing and Diagnosing Patients With Mood Disorders

Assessing and Diagnosing Patients With Mood Disorders

Subjective:

CC (chief complaint): “I can’t sleep much”.

HPI: 27-year-old female presenting to the clinic with complaints of being unable to get enough sleep. She finds trouble falling back to sleep, especially after putting her baby to sleep. She is uncomfortable with how she looks and expresses her desire to lose postpartum weight through running. She has been having problems in her relationships, cries all the time, yells a lot, and is easily irritated by things. She has been sexually inactive since her daughter was born two months ago, as she lacks sexual desire and drive. She is socially isolated. She quit her job on the suspicion that the job would end after her maternity leave. The client has lost interest in most things, including activities she used to like, such as writing. She feels terrible about her situation and thinks her husband is judging her. She has had suicide ideation but has been unable to act on it.

Past Psychiatric History:

• General Statement: The patient has a negative history of any psychiatric illness.
• Caregivers (if applicable): N/A
• Hospitalizations: No history of hospitalizations,

Medication trials: No history of medication trials.

Psychotherapy or Previous Psychiatric Diagnosis: No history of psychotherapy or previous psychiatric diagnosis.

Substance Current Use and History: No history of substance use.

Family Psychiatric/Substance Use History: Brother was addicted to methamphetamine and .  committed suicide.

Psychosocial: The patient is married. She had her first child two months ago. She currently stays at home after quitting her job as a librarian after five years.

Medical History: Has a history of hypertension.

• Current Medications: Trandate 100mg twice daily.
• Allergies:
• Reproductive Hx: The client has a two-month-old baby.

ROS:

• GENERAL: The patient reports having gained weight. Denies fevers, or chills.
• HEENT: No reports of head injuries, ear, eye, and nasal discharge, visual and hearing loss, sore throat, or difficulty swallowing.
• SKIN: No report of scars, lesions, color inconsistencies, or swelling on her skin.
• CARDIOVASCULAR: Denies palpitations, edema, or irregularities in her heart rate and rhythm.
• RESPIRATORY: Denies shortness of breath, wheezing, or unusual coughs.
• GASTROINTESTINAL: No report of abdominal pain, or bowel movement inconsistencies.
• GENITOURINARY: No reports of dysuria, frequent urination, urinary urgency, or changes in urine appearance.
• NEUROLOGICAL: No reports of headaches, dizziness, or syncope.
• MUSCULOSKELETAL: no reports of muscle and joint pain, muscle stiffness, or restriction in the range of motion of the joints.
• HEMATOLOGIC: no reports of unusual bleeding or anemia.
• LYMPHATICS: No reports of splenomegaly or lymph node swelling.
• ENDOCRINOLOGIC: No reports of heat or cold intolerance or diabetes.

Objective:

Physical exam:  Physical examination was negative except for constitutive symptoms which reveal postpartum weight gain. The patient also cried a lot during the interview.

Vital Signs:

T- 98.6 P- 88 R 18 154/92 Ht 5’1 Wt 230lbs

Diagnostic results: Not ordered. MDD is a clinical diagnosis made after a thorough history taking and examination,

Assessment:

Mental Status Examination: The client is alert and oriented to the place. She verbalizes where she is and what brought her to the clinic. She is responsive and answers the interview questions correctly and logically. Her judgment is intact. Her mood is sad as she cries a lot, even during the interview. Her speech is coherent and logical. She reports having experienced suicidal thoughts but has been able to attempt suicide as she cares for her family.

Differential Diagnoses:

Major depressive disorder (MDD) ICD-10 Code F330:  A diagnosis of MDD is made in the presence of a low mood or loss of interest in things, feelings of guilt, worthlessness or hopelessness, appetite changes, sleep disturbances, and suicidal ideations. According to the fifth generation of the Diagnostic and Statistical Manual for Mental Health Disorders (DSM-V), patients presenting with either a depressed mood or anhedonia, accompanied by other manifestations of depression, should be suspected of MDD (Mishra & Varma, 2023). The patient in the case presented had anhedonia, sleep disturbance, irritability, social isolation, feelings of guilt, and suicidal ideation. These symptoms affected her relationships with her husband and her job. This warranted the diagnosis.

Bipolar Disorder ICD-10 Code F31: Bipolar disorder manifests with alternate episodes of depression and mania. During the depressive episodes, patients may display symptoms similar to those of MDD (Goes, 2023). The patients in the case presented had symptoms similar to those of the depressive phase of bipolar, warranting the inclusion of this differential. This diagnosis was, however, ruled out due to the absence of manic episodes.

Adjustment disorder ICD-10 Code F43.2: Patients with adjustment disorders will often present with depressive symptoms such as crying easily, low energy, and hopelessness, coupled with anxiety, irritability, and sleep disturbance (O’Donnell et al., 2019). The patient in the case presented had symptoms similar to those of depression proceeding childbirth and neonatal care. This warranted the inclusion of this differential.

Reflections:

The interview details different assessment components for patients with psychiatric illnesses. I agree with my preceptor’s assessment and diagnostic impression. Notwithstanding, I would be keen to perform a detailed objective examination to capture the vital signs of the patient and the physical examination for pertinent systems. The legal consideration in this case is child custody evaluation. The patient in the case is at risk of self-harm, as demonstrated by the suicidal ideations. Likewise, assessment findings gave insight into the dysfunctionality of the family. Custody evaluation may allow the establishment of the living arrangement best suited for the child (Lee et al., 2020). An ethical consideration in the case is beneficence. Caregivers handling the client, in this respect,  should act in the best interest of the patients by making care decisions that optimize the client’s clinical outcomes. Access to mental healthcare is a social determinant of health, as displayed in the case. The therapist should maintain responsibility in ensuring the patient receives the mental healthcare she requires to lessen her culpability to self-harm. As a point of health promotion and illness prevention to the patient, she should be advised to present to the clinic with her husband to allow for a comprehensive management of her family’s case.

 References

Goes, F. S. (2023). Diagnosis and management of Bipolar Disorders. BMJ. https://doi.org/10.1136/bmj-2022-073591

Lee, M. H., Chung, D. S., Moon, D. S., & Kwack, Y. S. (2020). The concept and historical background of custody evaluation. Journal of the Korean Academy of Child and Adolescent Psychiatry, 31(2), 53–57. https://doi.org/10.5765/jkacap.200005

Mishra, A. K., & Varma, A. R. (2023). A comprehensive review of the Generalized Anxiety Disorder. Cureus. https://doi.org/10.7759/cureus.46115

O’Donnell, M. L., Agathos, J. A., Metcalf, O., Gibson, K., & Lau, W. (2019). Adjustment disorder: Current developments and Future Directions. International Journal of Environmental Research and Public Health, 16(14), 2537. https://doi.org/10.3390/ijerph16142537

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Accurately diagnosing depressive disorders can be challenging given their periodic and, at times, cyclic nature. Some of these disorders occur in response to stressors and, depending on the cultural history of the client, may affect their decision to seek treatment. Bipolar disorders can also be difficult to properly diagnose. While clients with a bipolar or related disorder will likely have to contend with the disorder indefinitely, many find that the use of medication and evidence-based treatments have favorable outcomes.

Assessing and Diagnosing Patients With Mood Disorders

RESOURCES

Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.

WEEKLY RESOURCES

TO PREPARE:
Review this week’s Learning Resources. Consider the insights they provide about assessing and diagnosing mood disorders.
Download the Comprehensive Psychiatric Evaluation Template, which you will use to complete this Assignment. Also review the Comprehensive Psychiatric Evaluation Exemplar to see an example of a completed evaluation document.
By Day 1 of this week, select a specific video case study to use for this Assignment from the Video Case Selections choices in the Learning Resources. View your assigned video case and review the additional data for the case in the “Case History Reports” document, keeping the requirements of the evaluation template in mind.
Consider what history would be necessary to collect from this patient.
Consider what interview questions you would need to ask this patient.
Identify at least three possible differential diagnoses for the patient.
BY DAY 7 OF WEEK 3
Complete and submit your Comprehensive Psychiatric Evaluation, including your differential diagnosis and critical-thinking process to formulate a primary diagnosis. Incorporate the following into your responses in the template:

Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What is 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 with supporting evidence, listed in order from highest priority to lowest priority. Compare the DSM-5-TR 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.
Reflection notes: What would you do differently with this client if you could conduct the session over? 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.).