Assessing and Diagnosing Patients With Mood Disorders
CC (chief complaint): Julie Houston is a 19-year old female presenting herself for psychiatric evaluation due to mood disorders. Her chief complaint is “just down. I’m not doing so well.”
HPI: Julie recently began a business undergraduate program; unemployed single and full-time students patient present for the psychiatric evaluation claims that her mother becomes concerned at a specific time of year every year due to the nature of her moods. When asked how she is feeling, she responds, “not great, just down and not doing so great patient struggles to concentrate and finds her class programs dull; in her own words, she describes them as “The teachers are getting to be a bit of a pain. The classes aren’t lustrous. I’m in this special business program, where you have to come up with a mock company. I just… I can’t seem to get it done. That, and all my other projects. I’m already late on two of them.” The description identifies symptoms of depression which include feeling down, leading to the lack of enthusiasm in her programs(A.P.A., 2014)). The patient responds to irregular sleep or eating patterns by describing that she gained weight and slept through five classes in the month, confirming the issue. The trait presents a symptom evident in most depression cases. She also dislikes the cold weather and has disassociated with most of her friends and social activities. The patient has no history of psychiatric or prescribed medication, nor does the family have a history of psychiatric disorders or substance use.
Past Psychiatric History:
There are no evident past psychiatric history records and assessments for the patient:
Substance Current Use and History:
No records provided currently for substance use before the psychiatric evaluation
Family Psychiatric/Substance Use History:
History: There is no psychiatric records or substance use for the family
Social history: Julie was born and raised in southern California, where she lived her whole life. She has a mother and a father, age not described. She also has two brothers and one sister, making it a family of four siblings. Currently, Julie is pursuing a business programme in Boston, MA, as a full-time student. She resides with two female roommates in the campus housing. Therefore, she is unemployed and financially dependent on her parents; she is not married and is in a single relationship. No legal hx NKDA are reported, no information on the traumatic history and violent hx. There is no medical record indicating past use of prescribed medication
According to information provided by the patient, the patient’s behavioural pattern is consecutively evident in every period with similar mood disorder patterns. The feeling lasts for a prolonged period indicating a severe mood disorder. Julia is raised by both the father and mother and is among three more siblings two brothers and one sister. The order in which she was born is not outlined upon reviewing records. The patient has a close relationship with the mother as she suggested the therapy to the patient due to worry of mood disorders. The family have resided in southern California for her entire life. The patient resides at the campus housing with her two roommates, where she is doing her business program. The patient is not married and is not involved in a relationship. She does not have any significant relations within the campus and no children.
- Current Medications: None
- Allergies: Unknown
- Reproductive Hx: Unknown
- GENERAL: Sleep and eating disorders gained weight
- HEENT: There are no headaches or dizziness, no changes in vision or pain. No ringing or hearing loss. There was no sinus inflammation, congestion, or nasal congestion. No mouth sores, swallowing disorders, dry mouth, or hoarseness.
- SKIN: There is no cyanosis. There are no abrasions or rashes.
- CARDIOVASCULAR: There were no mutterings or sinus tachycardia. There is no patellofemoral oedema.
- RESPIRATORY: There is no shortness of breath, orthopnea, wheezing, or coughing.
- GASTROINTESTINAL: no recent nausea, vomiting, diarrhoea, or constipation. no melena or hematochezia.
- GENITOURINARY: no signs of incontinence, hemoptysis, night sweats, or dyspareunia.
- NEUROLOGICAL: No migraine symptoms, dizziness, neuropathy, paralysis, ataxia, numbness, or tingling in the extremities.
- MUSCULOSKELETAL: No cramps, back pain, muscle aches, or rigidity.
- HEMATOLOGIC: no anaemia, scarring, or ligament damage.
- LYMPHATICS: No enlarged nodes. There is no history of surgical intervention.
- ENDOCRINOLOGIC: no family history of diabetes or thyroid issues. There has been no history of heat or cold intolerance or changes in the hair or skin. No polydipsia or polyuria.
Diagnostic results: T 98.1 P-78 R-18 119/74 Ht 5’2” Wt 184lbs
HEENT: Atraumatic, normocephalic head. The mucosa of the mouth is dry but free of lesions.
Neck: No cervical lymphadenopathies’ and no thyroid masses in the neck
Cardiovascular: No signs of change or gallops in the cardiovascular system.
Skin: No rashes or lesions on the skin.
Mental Status Examination:
The patient is neutrocistic exhibiting moodiness, emotional irritability causing passive responses visible with her facial expressions. She looks laboured in speech with late responses. The patient is audible and coherent with a little instance of shortened speech, but she exhibits clear language responses. Her body posture also characterises a depressive mood as she constantly looks down and tends to pull her arm sleeves frequently. The patient feels down and not great. It gets worse during winter as she dreads the season. She is easily annoyed and lacks interest in most social interactions, i.e. class programs, and friendly activities. Mainly she is depressed as she constantly shrugs on describing her experiences and constant sighs, illustrating speech labour characterising the depression. Cognitive functioning is fully oriented short term, and long term memory is intact. Reasoning and solving issues seem fair, subjecting her to be fully capable of knowledge. The patient has non-apparent signs of suicidal thoughts, visual or audio hallucinations
Individuals are diagnosed with depression with persistent low moods and anhedonia, inability to gain pleasure from normally exciting activities, feelings of guilt or worthlessness, a lack of energy, sleep and diet problems, difficulty concentrating, irritability, and suicidal thoughts. Diagnosis of depression can also be ruled out following various causes such as underlying medical conditions, medical induced depressive disorders, mood disorders, and schizophrenia to manage depression appropriately. The patient, therefore, has to be assessed following medical evaluations determining endocrinopathies, for example, diabetes, thyroid, and adrenal disorders, which are significant markers for a depression diagnosis (Bains & Abdijadid, 2021). The other differential diagnosis applicable to the patient would be the determination of nutritional deficiencies in her diet. Lack of vitamin D, B 12, B6, iron and phosphate also leads to the character development of depression symptoms. Neurological Causes may also be factors influencing diagnostic differences. The cause can be exhibited through cases of cerebrovascular accidents, Multiple Sclerosis, haematoma, seizures, neurological disorders such as Parkinson disease and Alzheimers (Sinrich, 2021). More differential diagnoses describe depression, such as malignancies, infectious diseases, and metabolic disturbances.
The DMS-5 classification of diagnosis for the mood disorder for patients are highlighted below following an ascending order in priority:
1: Bipolar 1 Disorders
The criteria for bipolar 1 disorder require identifying and understanding the classic manic depressive disorder. Two changes identifiable are elated irritability with the patient, characterised by moody or decreased enthusiasm while performing activities. The other change is the performance factor within activities, deeming them no longer enjoyable(Parker, 2014). Julie exhibits all symptoms of the disorder as she is irritable towards her learning activities and later the tendency to not perform well in social interactions. She also finds past enjoyable activities dull and does not perform actively.
2: Bipolar II disorders
The criteria for the diagnosis has a requirement of past hypomania or episodes of major depression. The diagnosis factors focus both on historical incidents and current incidents that may be prolonged within their onset(Parker, 2014). The patient exhibits a history of prolonged mood disorder when she describes the long sleeping periods, which led her to miss several of her classes 5 times a month. The assessment identifies the prevalence of major depression for the patient
3: Cyclothymic Disorders
The criteria for the assessment requires a periodic assessment of recurrent hypomania and significant depression cases within five years. The DMS-5 classification identifies the diagnostic requirement to be half that of the period states meaning if cases are extensive, the determination of major depression within the patient can be achieved (Parker, 2014). The premise for the diagnosis towards the client identifies the patient to have had the symptom for well over a year as she differs between two winter seasons within the years. Therefore, diagnosis of the symptoms identifies the prevalence of major depressive disorders.
The diagnosis criteria selected is through patient response. The approach is achieved as the patient refers to social activities as stressors, the irregular dietary and sleep patterns that foster the development of major depression. The attribute provides the necessary information to form a diagnostic evaluation for the patient. Pertinent positives notable with the patient are evident as she is correspondent to the provider’s evaluation, making diagnosis achievable. The negatives are unidentified as the patient is collaborative during the psychiatric evaluation
The patient Julie Houston exhibits clear symptoms of depression through the psych evaluation. The need for critically identifying the root of the problem is omitted provider does not identify the core factor for the mood disorder. The patient history of the disorder is long and left untreated, causing a major development of stressors such as the lack of concentration in the class, Lack of interest in social activities both in the classroom and with her friends, Negative attitude towards her peers and teacher which fosters an introvert culture (A.P.A., 2014). As a psychiatrist, identifying core beliefs is essential to understand the cause of the mood disorder. An underlying neurological incident might foster the pattern during the specific period. Identifying the factor will lead to a successful therapeutic intervention. The diagnosis of depression toward the patient is implicit as the symptoms are persistent for more than the stipulated period of two weeks. Therefore the patient should be provided with the necessary inpatient therapeutic care for 2 to 3 days a week to assess the mood disorder. Labs for CBC, electrolytes and TSH are also required before extensive therapy.
During the psychiatric evaluation, I’ve learnt effective treatment of depression and mood disorders requires a comprehensive approach to core factors: the patient’s environment, social interactions, psychiatric histories, and physical characters. Continuos therapy will help providers determine the best approach for the patient to modify her mood and improve health outcomes positively. The ethical considerations for psychiatric assessment for the patient are extensive and go beyond the confidentiality and informed consent criteria. The provide to client relationship entails a myriad of subjective considerations and rights regarding the issue being addressed and patients correspondence. Julie, a 19-year-old, is legally classified as an adult and has various rights that the clinician should maintain, such as privacy(Blunt, 2006). The risk factor considerations are also essential to ensure safety and effective therapy for the patient. PMH records should be used appropriately to maintain the privacy and protection of the patient. Conclusively, the psychiatric assessment follows a defined program that the patient and provider should follow effectively to improve the outcomes.
A.P.A. (2014). Bipolar and Related Disorders. Fifth Edition.American Psychiatric Association.
A.P.A. (2014). Diagnostic and Statistical Manual of mental disorders. Fifth Edition.American Psychiatric Association.
Bains N., and Abdijadid, S. (2021). Major Depressive Disorder. NCBI. Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK559078/
Blunt, D. R. (2006). Confidentiality, informed consent, and ethical considerations in reviewing the client’s psychotherapy records. (ERIC Document Reproduction Service No. ED490794)
Parker, G.F. (2014). DSM-5 and Psychotic and Mood Disorders. Journal of the American Academy of Psychiatry and Law.
Sarkhel, S. (2009). Kaplan and Sadock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry, 10th edition
Sinrich, J. (2021). What Is Major Depressive Disorder? Very well health. Retrieved from https://www.verywellhealth.com/major-depressive-disorder-5092483
“Training Title 2.”, directed by Anonymous, Symptom Media, 2016. Alexander Street, https://video.alexanderstreet.com/watch/training-title-2.
Assessing and Diagnosing Patients With Mood Disorders
Training Title 2
Name: Ms. Julie Houston
Gender: female Age:19 years old
T 98.1 P-78 R-18 119/74 Ht 5’2” Wt 184lbs
Background: Recently started a business undergraduate program in Boston, MA after growing up and living in South Carolina her whole life. Grew up with both parents, two brothers, and one sister. Currently lives in off-campus housing with two other female roommates. Currently a full-time student, not employed. Not married, currently single. She has no previous psychiatric history; takes no medications. There is no psychiatric or substance use history for her or family. No legal hx NKDA Symptom Media. (Producer). (2016). Training title 2 [Video]. https://video-alexanderstreetcom.ezp.waldenulibrary.org/watch/training-title-2
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. 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.
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 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.).
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