Case Study- Comprehensive Psychiatric Evaluation

Case Study- Comprehensive Psychiatric Evaluation

Subjective:

CC (chief complaint): “Depression for a few couple of days.”

HPI: The patient is a 16-year-old Caucasian female who came with a form written by her parents stating that she was depressed yesterday and a couple of times in recent weeks. However, the patient stated that she was not depressed but was in a rather bad mood. Her parents stated that she did not want to participate in school, but the patient stated that bad moods make her not want to sing. She states that the bad moods want to make her run away from everything. Her parents further wrote that the patient had no energy yesterday. The patient states that she is happy today, “yesterday was yesterday, and today is today.” Her parents further stated that the patient told them yesterday that she was worthless for destroying everyone’s lives. The patient, however, stated that that was ancient history. The patient states that what their parents wrote is their freedom of expression, which she believes in. Hire our assignment writing services in case your assignment is devastating you.

Past Psychiatric History:

General Statement: The patient has a history of treatment since seven for conduct disorder, depression, and a history of self-harm with cutting

Caregivers (if applicable): Not applicable

Hospitalizations: She has been hospitalized in a three-month teenager residential psychiatry facility, where she was discharged a month ago.

Medication trials: History of sertraline use that worsened her impulsivity, irritability, and aggression. She was discharged from the teen mental facility with lithium 300mg in the morning, 600 mg at bedtime, and aripiprazole 100mg in the morning. She, however, hid these medications, claiming they slowed her down and crushed her creativity.

Psychotherapy or Previous Psychiatric Diagnosis: Depression and conduct disorder since she was seven.

Substance Current Use and History: No known history of substance abuse

Family Psychiatric/Substance Use History: Her grandmother has a history of bipolar disorder, while her mother and her maternal aunt have anxiety

Psychosocial History: The patient lives with her parents and two siblings in Tacoma. She is a sophomore in high school. She is currently not partnered. She has no current legal issues. She has a history of domestic violence to her two younger siblings and her mother as a juvenile. She has a history of cannabis use.

Medical History: No medical issues.

• Current Medications: Lithium 300mg am and 600mg nocte and aripiripazole 100mg am
• Allergies: No known allergies.

• Reproductive Hx: She is bisexual and has unprotected sex. She is currently using Nexplanon implant as a contraceptive method.

ROS:

GENERAL: No weight loss, chills, fever, or fatigue.

HEENT: Eyes: No double vision, blurred vision, yellow sclerae, or visual loss. Ears: No hearing loss, tinnitus, or ear pain. Nose: No nasal congestion or sneezing. Throat: No sore throat.

SKIN: No itching or rash.

CARDIOVASCULAR: No chest pressure, chest pain, or chest pain. No peripheral edema or palpitations

RESPIRATORY: No dyspnea, sputum, or cough.

GASTROINTESTINAL: No nausea, vomiting, abdominal pain, or anorexia.

GENITOURINARY: NO burning sensation on urination. No urinary hesitancy, urgency, or odor.

NEUROLOGICAL: No syncope, headache, paralysis, dizziness, ataxia, tingling sensations in the extremities, and numbness. No loss in bladder control or changes in bowel movement.

HEMATOLOGIC: No bruising, bleeding, or anemia.

LYMPHATICS: No lymphadenopathy or history of splenectomy.

ENDOCRINOLOGIC: No heat or cold intolerance. No polydipsia or polyuria. No reports of sweating.

Objective:

Physical exam: Not applicable

Diagnostic results:

Magnetic resonance imaging was ordered to check for any brain trauma or damage (Wu et al., 2021). The results revealed no damage or symptoms; hence, her issues are mental

Assessment:

Mental Status Examination:

The patient is well-groomed with appropriate hygiene. The patient is talkative, excited, and energetic. The was disorganized and aggressive.  The patient had intense eye contact during the interview. The patient was fidgeting, pacing, and could not sit still. Her speech was pressured and fast. It wasn’t easy to interpret what she was saying. She was also emphatic and loud. Her mood was euphoric, with intense happiness and excitement. She was elated with positive energy, well-being, and enthusiasm. She had an extreme expression of emotion with grandiosity and excessive friendliness. She was irritable with feelings of anger and irritability. Her effect was intense. She had a flight of ideas and a disorganized thought process. Her speech was accelerated, and she switched from topic to topic. Her thought content was focused on self-aggrandizement, and she was easily distracted. Her short and long-term memory were intact. Her judgment was impaired. She had unprotected sex and stole her mother’s money. Her insight into the disorder was little.

Differential Diagnoses:

Bipolar I Disorder

To be diagnosed with Bipolar I disorder, the patient must have a manic episode preceded by or followed by major depressive episodes or manic episodes. The patient had depression previously before coming to the clinic, but now she has mania. The first criterion is an abnormally elevated mood and increased goal-oriented energy lasting at least a week (American Psychiatric Association, 2013). The patient had an elevated mood and increased energy that had been present for several weeks. Three other symptoms that must be present during this period include decreased need for sleep, distractibility, and excessive involvement in activities with negative consequences. The patient slept for three hours a day, was easily distracted during the interview, and had unprotected sex. The other criterion is that mood issues are severe enough to cause hospitalization (American Psychiatric Association, 2013). The patient was hospitalized for three months. The final criterion is that the symptoms are not caused by any medical conditions (American Psychiatric Association, 2013). The patient has no medical conditions. The symptoms of a major depressive episode include feeling sad or hopeless, diminished interest in pleasure, insomnia, loss of energy, and feeling of worthlessness (American Psychiatric Association, 2013). The patient had a depressed mood yesterday with no interest in pleasure; she felt worthless because she caused suffering to many people. She also had insomnia and a loss of energy. She meets the criteria for Bipolar I disorder.

Major Depressive Disorder (MDD)

MDD can also present with manic or hypomanic symptoms but for a short time. The symptoms of MDD include irritability, depressed mood, anhedonia, insomnia, psychomotor agitation, a feeling of worthlessness, and suicide attempts (Hasin et al., 2018). Even though the patient presents with all these symptoms, the depressive episode has been followed by a manic episode, which rules out this diagnosis.

Generalized Anxiety Disorder (GAD)

The excessive worry of anxiety is present for at least six months, and the patient finds it hard to control the worry.  The symptoms associated with the worry include restlessness, fatigue, difficulty concentrating, irritability, muscle tension, and sleep disturbances (Andrews et al., 2016). For an individual to be diagnosed with GAD, another mental condition should not describe the symptoms. Even though the patient presents with several GAD symptoms, this diagnosis is ruled out since she does not meet all the DSM-V diagnostic criteria.

Reflections:

If I conducted the session again, I would invite the patient’s parents to help elucidate more on the patient’s condition. This patient is a minor who is not emancipated, and hence, it is important to involve the parents in the decision-making process. The patient uses marijuana, which is legal to use. This may pose a legal and ethical dilemma on my part. I am obligated to maintain doctor-patient confidentiality. However, the patient is doing something illegal, reporting to the police. The patient has a history of mental disorders, and hence it is important to consider this when formulating a treatment plan.

 References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub.

Andrews, G., Mahoney, A. E., Hobbs, M. J., & Gunderson, M. (2016). DSM-5 generalized anxiety disorder: The product of an imperfect science. Treatment of generalized anxiety disorder, 1-18. https://doi.org/10.1093/med:psych/9780198758846.003.0001

Hasin, D. S., Sarvet, A. L., Meyers, J. L., Saha, T. D., Ruan, W. J., Stohl, M., & Grant, B. F. (2018). Epidemiology of adult DSM-5 major depressive disorder and its specifiers in the United States. JAMA Psychiatry, 75(4), 336. https://doi.org/10.1001/jamapsychiatry.2017.4602

Wu, C., Lin, T., Chiou, G., Lee, C., Luan, H., Tsai, M., Potvin, P., & Tsai, C. (2021). A systematic review of MRI neuroimaging for education research. Frontiers in Psychology, 12. https://doi.org/10.3389/

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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 diagnostic criteria for each differential diagnosis and explain what DSM-5 criteria rule 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.).