PRAC 6645 COMPREHENSIVE PSYCHIATRIC EVALUATION NOTE AND PATIENT CASE PRESENTATION ESSAY

PRAC 6645 COMPREHENSIVE PSYCHIATRIC EVALUATION NOTE AND PATIENT CASE PRESENTATION ESSAY

PRAC 6645 COMPREHENSIVE PSYCHIATRIC EVALUATION NOTE AND PATIENT CASE PRESENTATION ESSAY

Subjective:

CC (chief complaint): ‘I am sad everyday almost throughout the day and feel fatigued’

HPI:

J is a 43-year-old female that came to the unit for assessment with complaints of feeling sad everyday for almost throughout the day for the last three months. The client reported the symptom onset was gradual. She also reported that she feels tired almost everyday. She finds it difficult to initiate any activity and remain focused. The patient reported a reduction in her appetite. She also noted difficulties in falling asleep and maintaining sleep for the past month. She denied suicidal thoughts, attempts, or plans. She also denied substance use, medication use, or a medical condition.

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ESSAY

Past Psychiatric History:

• General Statement: ‘I am sad everyday almost throughout the day and feel fatigued’
• Caregivers (if applicable): none
• Hospitalizations:The patient denied any history of hospitalizations or surgery
• Medication trials: none
• Psychotherapy or Previous Psychiatric Diagnosis: The client denied any history of psychotherapy or previous psychiatric diagnosis.

Substance Current Use and History:

Family Psychiatric/Substance Use History: The patient denied any history of psychiatric conditions in the family. She also denied any history of substance use in the family.

Psychosocial History: The client reported that her family is her social support system. Church members also help her to overcome her challenges.

Medical History:

• Current Medications: The patient is currently not using any medications
• Allergies: The client denied any food, drug, or environmental allergies.

• Reproductive Hx: The client reported that her menarche was when she was 16 years. It was regular. She is currently post-menopausal. She has two children with no history of pregnancy loss. She denied any history of sexually transmitted infections. She denied dysuria, urgency, and frequency. Her last Pap smear was two years ago and was unremarkable.

Objective:

Diagnostic results: Thyroid function tests and complete blood count were ordered. The results were within the normal ranges for these laboratory investigations.

Assessment:

Mental Status Examination: The patient was dressed appropriately for the occasion. She appeared fatigued during the assessment. She was oriented to self, others, time, and events. Her mood was depressed with flat affect. Her speech was slightly reduced in terms of volume and rate. She maintained normal eye contact and did not demonstrate any abnormal mannerisms such as tics. She denied illusions, delusions, and hallucinations. She also denied suicidal thoughts, plans, or attempts.

Differential Diagnoses: The client’s primary diagnosis is major depression. According to DSMV, major depression is characterized by symptoms such as depressed mood, hopelessness, anhedonia, feeling fatigued, and difficulty in concentration. Patients also experience changes in appetite, concentration ability, and insomnia. They also experience suicidal thoughts, attempts, or plans. These symptoms affect their functioning and cannot be attributed to causes such as medication use, substance abuse, or medical conditions and (Kraus et al., 2019; Monroe & Harkness, 2022; Semkovska et al., 2019). The client’s symptoms align with these, hence, a diagnosis of major depression.

Secondary diagnoses that should be considered include hypothyroidism and insomnia. Patients with hypothyroidism experience symptoms such as feeling fatigued, depressed, weight gain, and cold intolerance. Laboratory investigations ruled out hypothyroidism as the cause of the client’s problem. Insomnia is the least likely diagnosis since patients do not experience symptoms of depressed mood (Chiovato et al., 2019; Hertenstein et al., 2019).

Reflections Notes: I would use tools for assessing rating depression such as PHQ-9. I will need to research on the effect of socioeconomic status on the access to healthcare among patients suffering from depression. One of the patient education consideration to improve health disparities and inequities is health education to empower her be responsible for her health.

Case Formulation and Treatment Plan:  The patient was prescribed antidepressants and monthly individual cognitive behavioral therapy. The principle underlying cognitive behavioral therapy is that it transforms the patient’s maladaptive thoughts that contributing to depression. The patient’s follow-up will be after four weeks. The patient will be referred for group psychotherapy during the next visit based on her response to treatment.

I confirm the patient used for this assignment is a patient that was seen and managed by the student at their Meditrek approved clinical site during this quarter course of learning.

Preceptor signature: ________________________________________________________

Date: ________________________

 

References

Chiovato, L., Magri, F., & Carlé, A. (2019). Hypothyroidism in Context: Where We’ve Been and Where We’re Going. Advances in Therapy, 36(2), 47–58. https://doi.org/10.1007/s12325-019-01080-8

Hertenstein, E., Feige, B., Gmeiner, T., Kienzler, C., Spiegelhalder, K., Johann, A., Jansson-Fröjmark, M., Palagini, L., Rücker, G., Riemann, D., & Baglioni, C. (2019). Insomnia as a predictor of mental disorders: A systematic review and meta-analysis. Sleep Medicine Reviews, 43, 96–105. https://doi.org/10.1016/j.smrv.2018.10.006

Kraus, C., Kadriu, B., Lanzenberger, R., Zarate Jr., C. A., & Kasper, S. (2019). Prognosis and improved outcomes in major depression: A review. Translational Psychiatry, 9(1), Article 1. https://doi.org/10.1038/s41398-019-0460-3

Monroe, S. M., & Harkness, K. L. (2022). Major Depression and Its Recurrences: Life Course Matters. Annual Review of Clinical Psychology, 18(1), 329–357. https://doi.org/10.1146/annurev-clinpsy-072220-021440

Semkovska, M., Quinlivan, L., O’Grady, T., Johnson, R., Collins, A., O’Connor, J., Knittle, H., Ahern, E., & Gload, T. (2019). Cognitive function following a major depressive episode: A systematic review and meta-analysis. The Lancet Psychiatry, 6(10), 851–861. https://doi.org/10.1016/S2215-0366(19)30291-3

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Review this week’s Learning Resources and consider the insights they provide about clinical practice guidelines.

Select a group patient for whom you conducted psychotherapy for a mood disorderduring the last 4 weeks. Create a Comprehensive Psychiatric Evaluation Note on this patient using the template provided in the Learning Resources. There is also a completed template provided as an exemplar and guide. All psychiatric evaluation notes must be signed by your Preceptor. When you submit your note, you should include the complete comprehensive psychiatric evaluation note as a Word document and pdf/images the completed assignment signed by your Preceptor. You must submit your note using Turnitin.