Comprehensive Psychiatric Evaluation-Depression and Anxiety

Comprehensive Psychiatric Evaluation-Depression and Anxiety

Subjective

CC (chief complaint): The Patient was a referral case for the treatment of severe depression and anxiety. This is not her first time having depressive symptoms, as she was hospitalized twice in the past year. The anxiety and depression symptoms have greatly diminished her social and daily functioning to the extent she has missed her college classes despite being on medication. She, too, has had various instances of suicidal ideation and thoughts.

HPI: Patient XX-AN is a 22-year-old female who presents with depression and anxiety. She was referred to the clinic after having two previous hospitalization cases related to previous episodes of depressive symptoms for further evaluation and treatment. The depressive symptoms and anxiety have impacted her at a functional level, and she has been unable to attend her college classes. She also has severe suicidal ideation and thoughts. Extensive research has shown that anxiety symptoms among university students are high as 24.5%, 26.1% for depressive symptoms, and over 18.8% for suicidal ideation (Paula et al., 2020). She has a fluoxetine prescription; however, she admits she has not been compliant with taking her medication.

Past Psychiatric History:

General Statement: Patient XX-AN has a psychiatric history involving depressive symptoms. This has led her to be admitted twice and put under medication. The anxiety symptoms and suicidal ideation and thoughts had not been identified in her previous hospitalizations or diagnoses prior to this reference. She has been treated with pharmacotherapeutic interventions but is non-compliant. Hire our assignment writing services in case your assignment is devastating you.

Caregivers (if applicable): N/A.

Hospitalizations: She has been admitted twice in the past year with psychiatric diagnoses involving depressive symptoms.

Medication trials: the patient has a prescription of fluoxetine antidepressant of the selective serotonin reuptake inhibitor class.

Psychotherapy or Previous Psychiatric Diagnosis: The Patient has never received any psychotherapy. She was put under pharmacotherapy after she was diagnosed with depressive symptoms from her previous hospitalizations.

Substance Current Use and History: Patient XX-AN does not have a history of substance use. She is also not currently using or abusing any substance.

Family Psychiatric/Substance Use History: The referral did not mention any instances or history of substance use or cases of psychiatric concern in the family. Therefore, it is assumed that there is no history of psychiatric issues or substance use in the family. Further follow-up on family members, especially the mother, father, and immediate grandparents, is needed.

Psychosocial History: Patient XX-AN is currently a college student and has no children of her own nor registration of work. She has had previous episodes of depressive symptoms, which has affected her at a functional level. She has not recorded legal issues or criminal history. Further details will be obtained from the reference.

Medical History: She has had previous episodes of depressive symptoms.

Current Medications: Fluoxetine 20mg

Allergies: Patient XX-AN has not recorded allergies to medications, food, related food substances, environmental allergens, or drug intolerance that are a threat to her well-being and safety.

Reproductive Hx: Patient XX-AN has not expressed any reproductive or sexual health concerns, and no history of contraceptive use has been provided.

ROS:

GENERAL: Slight weight gain. Denies fatigue, fever, or chills. Positive for general weakness.

HEENT: Persistent headaches reported. Eyes: negative for diplopia, blurry vision, yellow sclerae, or visual loss. Instances of photophobia. Ears: Negative for hearing loss, otorrhea, and tinnitus. Nose: No case of epistaxis and sneezing. Throat: Negative for sore throat and dysphagia.

SKIN: Negative for itching and rash

CARDIOVASCULAR: Negative for chest pain, chest pressure, palpitations, tightness, and any chest discomfort. No pedal edema.

RESPIRATORY: Negative for coughing, wheezing, shortness of breath, and sputum.

GASTROINTESTINAL: Patient denies experiencing nausea or vomiting. Negative for diarrhea, abdominal congestion, and constipation. Negative for blood in the stool. Reported abdominal pains.

GENITOURINARY: No menses at the time of presentation. Negative for burning on urination, hesitancy, odour, and odd colour.

NEUROLOGICAL: Positive for headaches. Denies dizziness, syncope, paralysis, ataxia, numbness, and tingling in the extremities. The patient has maintained normal bowel and bladder passage.

MUSCULOSKELETAL: Has slight muscle aches and pain, and back pain. Denies joint stiffness and joint pain.

HEMATOLOGIC: The patient has no history of blood disorders, including clotting disorders. Negative for bleeding and bruising.

LYMPHATICS: No lymphadenopathy. No history of splenectomy.

ENDOCRINOLOGIC: No reported episodes of sweating, cold, or heat intolerance. Negative for polyuria or polydipsia.

 Objective

Physical exam:

Vital signs: T 98.40, RR 17, non-labored, BP 128/86, P 78, HR 89, BMI 26.8 kg/m2

General: A&O x3. Well-groomed for the occasion. Has low energy and feels like she is “slowing down.” Experiencing difficulties concentrating on the occasion and is unable to recall simple things. Has difficulties deciding what she wants. Has insomnia and is openly restless and quite irritable. Feels worthless and empty. Has strong suicidal ideation and thoughts.

HEENT: Complaints of recurrent headaches. Highly reacts to light, and pupils seem a bit dilated. Extraocular movements are intact. Normal earlobes. Negative for fluid on both ears on otoscopy. No nasal turbinate inflammation. No sneezing. No exudate.

Neck: Minor scratches on the neck, red ring on the neck. Normal jugular and no distensions.

Chest/Lungs: Clear, no wheezing, non-labored breathing. No crepitations. I: E of 3:1.

Heart/Vascular: S1 and S2 heard. No aortic stenosis. No pulmonary stenosis. No mitral valve prolapses.

Diagnostic results:

Lab: Beck Depression Inventory (BDI) score of 49.

Assessment

Mental Status Examination

The Patient is a 22-year-old female who is aware and oriented to person, location, time and event. She is well-dressed for the occasion. Has added slight weight. Her communication is good; however, she tends to be easily bored and disorientated. She is monotonous, has no current social life, clearly lacks energy, talks of feeling slowed down, and has avoidant eye contact; however, she has no issues with mannerisms and tics. Her mood is low and empty; she is quick to anger, irritate, and becomes restless during a conversation. She loses track of the conversation and cannot remember minor details. Inadequacy in insight and judgment and deluded of death escapism with suicidal thoughts. Diagnosis:  Major Depressive Disorder (MDD) (BDI 49).

Differential Diagnoses:

Major depressive disorder: The most probable diagnosis of Patient XX-AN is Major Depressive Disorder (MDD) or severe depression. This diagnosis has been concluded as the symptomatology manifested aligns with the DSM-5 diagnostic criteria for MDD. According to the DSM-5, MDD can be diagnosed if the Patient, in the last two weeks and previous episodes, has i) depressed moods, ii) significant weight loss or gain in the last month, iii) loss of interest in pleasurable activities, iv) low energy, v) insomnia, vi) inability to concentrate, vii) recurrent suicidal thoughts and ideations, and viii) feeling worthless (American Psychiatric Association, 2022). All considerations have been critically made to ensure that symptoms that can be attributed to medical and mental disorders have not been included in the development of this diagnosis. Due to the symptomatology, Patient XX-AN most likely has MDD (F33.2).

Bipolar disorder: Bipolar disorder is the second most probable diagnosis of Patient XX-AN. The Patient displays the MDD symptoms listed above. However, the differentiating features include i) increased impulsivity, ii) episodes and symptoms of disruptive mood dysregulation disorder, iii) increased activity, iv) elevated moods, v) grandiosity and other bipolar-specific characteristics such as talkativeness (American Psychiatric Association, 2022). Most of these symptoms are absent in Patient XX-AN.

Anxiety disorder: Anxiety disorder is the third possible diagnosis. It is a common comorbidity in 75 percent of patients with MDD and bipolar disorders (American Psychiatric Association, 2022). Some of the non-specific symptoms presented in Patient XX-AN align with the DSM-5 diagnostic features of comorbid anxiety disorder.

 Reflections

All procedures for evaluating a psychiatric patient have been considered during the assessment of this Patient. However, I would suggest further evaluation with more information on the Patient’s family history, background, and other social experiences prior to this diagnosis. Healthy People 2030 considers the social and community context as a critical determinant of health (health.gov, n.d.). In this case, her social and family history and background are considered to contribute to the development of depressive and anxiety disorders (Lee et al., 2022). As a future advanced provider, one health promotion activity for this Patient is to engage in physical exercises, probably in a community gym. For her health education, I would advise her to avoid situations or environments that lead to experiences of sadness and suicidal thoughts.

References

American Psychiatric Association. (2022). DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS (5th ed.). American Psychiatric Association. https://drive.google.com/file/d/1K9nOTLZLKWaaVz231Xylxy_KJtEpsZnM/view.

health.gov. (n.d.). Social Determinants of Health. Healthy People 2030. Retrieved January 5, 2023, from https://health.gov/healthypeople/priority-areas/social-determinants-health

Lee, H. Y., Lee, L. H., Luo, Y., Penmetsa, P., Adanu, E. K., Li, X., Lidbe, A., & Jones, S. (2022). Anxiety and Depression amongst African-Americans Living in Rural Black Belt Areas of Alabama: Use of Social Determinants of Health Framework. The British Journal of Social Work, 52(5), 2649–2668. https://doi.org/10.1093/BJSW/BCAB199.

Paula, W. de, Breguez, G. S., Machado, E. L., & Meireles, A. L. (2020). Prevalence of anxiety, depression, and suicidal ideation symptoms among university students: a systematic review / Prevalência de sintomas ansiedade, depressão e ideação suicida entre estudantes universitários: uma revisão sistemática. Brazilian Journal of Health Review, 3(4), 8739–8756. https://doi.org/10.34119/BJHRV3N4-119.

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Assessment: What were your differential diagnoses? Provide a minimum of three (3) possible diagnoses. List them from highest to lowest priority. What was your primary diagnosis, and why?

Mental Status Examination:

Differential Diagnoses:

Reflections:

Reflection notes: What would you do differently in a similar patient evaluation? Reflect on one social determinant of health according to HealthyPeople 2030 (you will need to research) as applied to this case in the realm of psychiatry and mental health.  As a future advanced provider, what are one health promotion activity and one patient education considerations for this patient for improving health disparities and inequities in the realm of psychiatry and mental health? Demonstrate your critical thinking.