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Comprehensive Psychiatric Evaluation and Differential Diagnosis- Critical-Thinking Process for Primary Diagnosis Template

Maureen

Comprehensive Psychiatric Evaluation and Differential Diagnosis- Critical-Thinking Process for Primary Diagnosis Template

Subjective:

CC (chief complaint):

The patient reports she has not been doing well lately.

HPI: V.H., a 17-year-old African American female, presents for psychiatric evaluation. She is currently a student in school and is not prescribed any psychotropic medications. She is referred for examination because of her feelings of low mood and difficulty in different life aspects.

The patient reports that she has been experiencing a decrease in mood during this time of the year, pointing out a pattern of feeling moody annually. She describes not doing well and feeling down, with memory problems and difficulties concentrating. She reports difficulty in school, specifically with finishing projects and assignments. The patient mentions a lack of interest in activities she enjoyed before, like hanging out with friends and participating in concerts. Also, she expresses a dislike for the cold, grey weather of the season, which aggravates her feeling of misery. The patient notes alterations in her eating and sleeping patterns, including sudden weight gain and dozing off in classes. Moreover, she reports feeling disconnected from her friends, finding their activities unappealing and dull.

Past Psychiatric History:

The patient has no significant psychiatric history reported.

The patient mentions she is accompanied by her mother, who is worried about her mood during this time of year.

There is no history of hospitalization. No history of suicidal ideation. No history of self-harm behaviors.

No history of medication trials.

The patient reports not undergoing any psychotherapy.

Substance Current Use and History: Patients report using caffeine and alcohol only. She takes at least two and a maximum of four cups a day of coffee. She reports taking alcohol occasionally, mainly during social gatherings. There is no mention of alcohol use dependence. She denies the use of other illicit substances.

Family Psychiatric/Substance Use History: No mention of family psychiatric history. The patient, however, confirms a history of alcohol use in the family but denies any significant psychiatric illness.

Psychosocial History: The patient was born and raised by her parents. She has two siblings. She is currently single and lives with her mother. She is currently attending school and expresses dissatisfaction with the cold weather and changes in the city during this time of the year. No significant legal history or trauma history was reported.

Medical History:

The patient has no significant medical history reported.

ROS:

Objective:

Physical exam: if applicable

Diagnostic results:

Thyroid function test- all parameters within normal ranges

Complete Blood Count- all parameters within normal ranges

Basic Metabolic panel- all parameters within normal ranges

Vitamin D levels- low levels

Assessment:

Mental Status Examination:

V.H. is a 17-year-old African American female who appears her stage age. She presents as cooperative with the examiner. She is appropriately dressed and neatly groomed. There are no observable signs of abnormal motor activity. During the interview, V.H.’s speech is clear, coherent, and of low volume and tone. Her thought processes seem logical and goal-oriented, with no evidence of looseness of association or flight of ideas. V.H. described her mood as consistently low, congruent to affect, expressing sadness and despondency. Even though she smiles sometimes, it appears forced and not reflective of genuine happiness. She denies any visual or auditory hallucinations. There is no evidence of thought content disturbances or delusional thinking. She denies any suicidal or homicidal ideation or any thoughts of self-harm. However, she expresses feelings of worthlessness and hopelessness. Cognitively, V.H. appears alert and oriented to place time, person, and situation. Her remote and recent appear intact. Her immediate memory and concentration seem impaired as she reports difficulty retaining information and forgetfulness. She has limited insight, as she struggles to point out the reasons behind her low mood and difficulty functioning, but acknowledges the effect of seasonal changes on her behavior and mood.

Differential Diagnoses:

Seasonal Affective Disorder: This disorder is mainly characterized by the patient experiencing depressive symptoms at a particular time of the year. This is in line with the patient’s dissatisfaction with the grey and cold weather and changes in the city during this time of the year, difficulty in concentrating, change in sleep patterns, social withdrawal, and anhedonia (Drew et al., 2021).

Pertinent positives include low vitamin D levels in the body, recurrent mood disturbance patterns during particular seasons, dissatisfaction with seasonal changes, and changes in sleep patterns and appetite (Drew et al., 2021).

Pertinent negatives include the absence of psychotic symptoms, hypomanic or manic episodes outside of the seasonal pattern, and key stressors unrelated to changes in seasons (Drew et al., 2021).

Dysthymic disorder: This condition features a history of recurrent mood disturbances during particular times of the year and chronic feelings of low mood. The patient’s dissatisfaction with the changes in the city and weather suggests a long-term pattern of depressive symptoms (Buelt & McQuaid, 2023).

Pertinent positive: Recurrent seasonal exacerbations of depressive symptoms, chronic low mood feelings lasting for not less than two years (Buelt & McQuaid, 2023).

Pertinent negative: Absent severe symptoms like significant functional impairment and suicidal ideation that meet Major Depressive Disorder diagnostic criteria (Buelt & McQuaid, 2023).

Adjustment disorder with depressed mood: The patient reports mood decline and difficulties in different life aspects like social and school activities, which are characteristics of this condition (O’Donnell et al., 2019).

Pertinent positives: The existence of stressors causing the onset of depressive symptoms like academic pressure and seasonal changes (O’Donnell et al., 2019).

Pertinent negatives: Symptoms are not resolved after six months of the stressor’s ending, and there is an absence of definitive precipitating events apart from seasonal changes (Geer, 2023).

Reflections:

Upon reflection and scrutiny of the case study, I am confident that the assessment and diagnostic impression are correct. This is because the patient’s symptoms are consistent with a diagnosis of seasonal affective disorder, which is a form of Major Depression Disorder with a seasonal pattern whereby there is a recurrent pattern of mood disturbance at particular times of the year. Taking part in the case study analysis has helped me learn a lot. This particular case underscores the effect of seasonal changes on mood and overall well-being. In this case, I would have acted differently by taking environmental factors into consideration when coming up with the diagnosis.

Ethical consideration in this specific case is upholding patient autonomy in treatment decisions. This involves discussing treatment options, possible side effects of medications, and the importance of therapy when used together with pharmacotherapy with the patient. It is crucial to take into consideration cultural factors that influence treatment and prevention preferences and the patient’s depression experience. Also, addressing social determinants of health, like access to mental health resources and support systems, is key for promoting overall health and treatment adherence.

References

Buelt, A., & McQuaid, J. R. (2023). Comparing Clinical Guidelines for the Management of Major Depressive Disorder. American Family Physician, 107(2), 123–124. https://www.aafp.org/pubs/afp/issues/2023/0200/editorial-major-depressive-disorder-guidelines.html

Drew, E. M., Hanson, B. L., & Huo, K. (2021). Seasonal affective disorder and engagement in physical activities among adults in Alaska. International Journal of Circumpolar Health, 80(1), 1906058. https://doi.org/10.1080/22423982.2021.1906058

Geer, K. (2023). Adjustment Disorder. Primary Care: Clinics in Office Practice, 50(1), 83–88. https://doi.org/10.1016/j.pop.2022.10.006

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/

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Question 

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.

Comprehensive Psychiatric Evaluation and Differential Diagnosis- Critical-Thinking Process for Primary Diagnosis Template

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.

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 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.).

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