Comprehensive Psychiatric Evaluation Note and Patient Case Presentation
Comprehensive Psychiatric Evaluation Note and Patient Case Presentation
HPI: Patient is a 15 years old Caucasian male with a history of depression, anxiety, mood instability, and SIB who presents to this outpatient treatment program as stepdown from inpatient where he was admitted for SI and SIB.
Patient reports SI since the age of 13 – 14 years old and was seeing a therapist twice a month. However, SI worsened in April 2021 at age 15 years old due to stress and anxiety related to school and relationship with girlfriend. Patient was brought to the emergency department (ED) for feeling unsafe at home due to identified method (cut wrist with a knife, overdose on medication, jump from a bridge) but no plan. At the time patient was taking Concerta for then recently diagnosed ADHD. However, Concerta was ineffective and possibly caused loss of appetite. Patient was hospitalized in inpatient psychiatric unit from 4/7/2021 – 4/27/2021 and attended intensive outpatient (IOP) treatment from 4/28/2021 – 5/25/2021, and thereafter, continued traditional outpatient. On 8/15/2021, a day prior to school starting patient returned to ED for SI and laceration requiring sutures. Patient reports school starting was a major stressor especially due to ex-girlfriend going to the same school. Patient was admitted to inpatient psych till 8/24/2021. During this hospitalization patient disclosed being bisexual and parents appeared to have been understanding and supportive. Patient stepped down to partial hospitalization (PHP) as of 8/26/2021. Patient had multiple medication changes since his first inpatient admission in April 2021, however, reports no improvement. Patient reports depressed mood, anhedonia, loss of energy, poor concentration, feelings of hopelessness, irritability, and isolation. Patient reports getting at least 8 hours of sleep every night, however, he wakes up a lot. Patient also reports decrease in appetite, however, gained weight due to eating unhealthy and not being physically active. Per mother, patient used to be in a swim team but hasn’t been doing any physical activity lately. Per mother, patient has poor hygiene and showers once a week with reminders.
Patient currently endorsing symptoms consistent with a DSM5 diagnosis of major depressive disorder without psychosis (MDD), generalized anxiety disorder (GAD), social anxiety disorder, and attention deficit hyperactivity disorder (ADHD).
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Past Psychiatric History:
General Statement: ‘I feel like taking my life and injuring myself.’
Caregivers (if applicable): Mother and father since patient is a minor. However, patient is independent to care for self.
Hospitalizations: Inpatient psychiatric admission 4/7/2021 – 4/27/2021, Intensive outpatient 4/28/2021 – 5/25/2021, inpatient 8/15/2021 – 8/24/2021
Medication trials: Concerta (ineffective), Zoloft (ineffective), Seroquel (hand tremors).
Psychotherapy or Previous Psychiatric Diagnosis: Patient was seeing therapist twice a month prior to first inpatient admission. History of depression, anxiety, and ADHD.
Substance Current Use and History: denies
Family Psychiatric/Substance Use History: There is history of anxiety in the client’s family. His father was diagnosed with anxiety disorder when he was 35 years. There is no other history of psychiatric condition or substance abuse.
Psychosocial History: Patient is a student in sophomore year at a local high school with 504 plan for ADHD. Lives at home with mother, father, and a 17 years old brother. Patient is single and in no relationship currently (broke up with girlfriend). Used to be in a swim team, but currently does not exercise or swim.
Medical History: The client has history of two hospital admissions due to suicidal ideations and self-injury. The first admission was between 4/7/2021 and 4/27/2021 while the second admission was 8/24/21-8/26/21. He has no other history of hospital admission.
Current Medications: the client is currently using Sertraline (Zoloft) 200 mg daily, Seroquel 200 mg nightly, Strattera 80 mg daily, and Hydroxyzine 50 mg twice daily as needed for anxiety.
Allergies: The client denied any food, drug, or environmental allergen.
Reproductive Hx: The client denied any history of sexually transmitted infections. He is bisexual. He is single and recently broke up with his girlfriend. He denied increase in urinary urgency and frequency as well as burning sensations during urination.
GENERAL: The client is alert and oriented x 4, disheveled in clothing appropriately for the weather and occasion and appears in no acute distress.
HEENT: No head injury, vision/hearing change, use of contacts, eyeglasses, or hearing aid/ear tubes, change in taste or smell, drainage, problem swallowing.
SKIN: Multiple scabs and cuts on left arm. No discoloration, rashes, sores, or any other skin abnormalities.
CARDIOVASCULAR: No chest pain, palpitations, syncope or edema.
RESPIRATORY: No shortness of breath, wheezing, or cough.
GASTROINTESTINAL: No nausea/vomiting/diarrhea/constipation
GENITOURINARY: No hematuria/incontinence/polyuria/pain on urination/flank pain/discharge.
NEUROLOGICAL: Mild hand tremors, possible from Seroquel. No head trauma/dizziness/seizure/lightheadedness/loss of coordination/tics/weakness/falls. MUSCULOSKELETAL: No muscle pain/joint pain/back pain/muscle weakness/gout/arthritis.
HEMATOLOGIC: No anemia/easy bruising/unusual bleeding/blood related disorders LYMPHATICS: No palpable nodes/painful or swollen lymph nodes. ENDOCRINOLOGIC: No diabetes/thyroid disorder/polyuria/polyphagia/polydipsia/ hormonal changes/intolerance to heat or cold.
Diagnostic results: The patient this case study is experiencing symptoms that align with those of depression. Diagnostic investigations used in depression are therefore required. The most appropriate diagnostic investigation is the administration of the Patient Health Questionnaire-9 (PHQ-9). PHQ-9 is a nine-item questionnaire that is administered to patients to determine the severity of major depression being experienced by a client. There is also the need to use other diagnostic tools such as the Beck Depression Inventory (BID), which has 21 sets of questions that can be used in measuring the feelings of the patients and severity of the depressive symptoms. Self-evaluation tools such as the Center for Epidemiologic Studies-Depression Scale may be administered for the client to evaluate his behavior, feelings, and outlook as experienced in the past week (Rice et al., 2019). The client also has a history of anxiety disorder. The provider can therefore use physical examination and history taking findings to rule out anxiety disorder. Similar approach is recommended for ruling out attention deficit hyperactive disorder, as the client has a history of its diagnosis.
Mental Status Examination: The client is a 15-year-old Caucasian male who appeared dressed appropriately for the occasion, however, disheveled. The client is oriented to self, place, time, and events. He is calm and cooperative with restricted affect. His judgment is fair. He denies illusions, delusions, and audio/visual hallucinations. His self-reported mood is depressed. He appears tired during assessment. He maintains occasional eye contact and responds to assessment questions as expected. He sustained attention and concentration during the assessment. His short-term and long-term memory is grossly intact as evidenced by re-collection of events. He appears to have mild hand tremors, which may be a side effect from Seroquel and patient states he doesn’t mind that since Seroquel is working well. His speech is soft and low tone. He reports suicidal thoughts without plan. His thoughts are future oriented.
Major depressive disorder without psychosis (MDD): Major depressive disorder without psychosis is the primary diagnosis for this client. He has symptoms that align with those of the disorder, as stated in DSMV. According to DSMV, a patient is diagnosed with depression if they experience symptoms of depressed mood or loss of pleasure or interest within a 2-week period. The symptoms include depressed mood in most of the days, nearly every day, significantly diminished interest or pleasure, weight loss or gain, slowed thought process and reduction in physical activity, fatigue, and feelings of hopelessness or guilt. Patients also experience recurrent suicidal thoughts, plans, or attempts with some having history of self-injuries (Rice et al., 2019). The client in the case study has more than five of the above symptoms, hence, making major depression without psychosis the primary diagnosis to consider.
Generalized anxiety disorder (GAD): Generalized anxiety disorder is the secondary diagnosis that should be considered since the client has history of anxiety disorder. According to DSMV, patients are diagnosed with generalized anxiety disorder if they present with symptoms of excessive worry and anxiety occurring in most of the days for at least six months. Patients have excessive worry and anxiety about aspects such as school performance and work. The other symptoms include difficulties in controlling the worry and association with symptoms such as irritability, muscle tension, sleep disturbance, difficulties in concentration, easy fatigability, and restlessness. The symptoms cause significant impairment in one’s functioning (Toussaint et al., 2020). While the client in the case study has worry about school, he has symptoms of self-harm, depressed mood, and suicidal thoughts, hence, eliminating the diagnosis of generalized anxiety disorder.
Social anxiety disorder: Social anxiety disorder is the other secondary diagnosis to be considered for the client in this case study. Accordingly, patients diagnosed with social anxiety disorder experience symptoms such as intense, persistent anxiety about specific social situations that one perceives that they can be embarrassed or judged negatively. Patients also show avoidance behaviors of situations that produce anxiety or endures them with intense anxiety or fear. The anxiety is excessively out of proportion and interferes with the normal functioning of the patients (Leichsenring & Leweke, 2017). While this disorder might be considered, the presence of symptoms such as suicidal thoughts and depressed mood eliminate it.
Attention deficit hyperactivity disorder (ADHD): ADHD is the other secondary diagnosis to be considered for the client, as he has a history of its diagnosis. Patients with ADHD experience a wide range of symptoms that mainly fall into the categories of inattention or hyperactivity. The symptoms include failure to pay attention to details, difficulties in undertaking complex tasks and following instructions, trouble in getting organized, and being easily distracted (Sibley et al., 2018). The client does not have these symptoms, hence, less considered in the treatment plan.
Reflections: I believe that the diagnosis of the client with major depression is correct. The client presented with symptoms that aligned with those of major depressive episode, as stated in DSMV. Major depression can affect one’s functioning in social aspects such as work and academics. The prescription of antidepressants for the client is appropriate to manage the depressive symptoms. Incorporation of psychotherapy is an excellent choice for this case. Psychotherapy would improve the effectiveness of the antidepressants and the coping of the client with depressive symptoms. Involvement of family in patient’s overall care will benefit both patient and provider so that optimal health results could be reached. Group therapy/counseling is another excellent approach to helping client obtain skills needed to care for self and cope with depression and triggers.
Case Formulation and Treatment Plan:
The client in this case study has severe symptoms of major depression without psychosis. The most appropriate treatment at the moment is increasing the dosage of Zoloft from 200 to 250 mg daily since it has been effective and increasing the dose seems appropriate at this time to see if it will result in further symptom improvement (Hengartner, 2020). The client should also be initiated on individual and group psychotherapy. Group psychotherapy will help the client learn from others about the effective coping skills with depression. It will also help in transforming the negative thoughts and beliefs that the client has about self and others (Cuijpers et al., 2020). I would also educate him about the importance of treatment adherence for optimum symptom management.
Cuijpers, P., Karyotaki, E., Eckshtain, D., Ng, M. Y., Corteselli, K. A., Noma, H., Quero, S., & Weisz, J. R. (2020). Psychotherapy for Depression Across Different Age Groups: A Systematic Review and Meta-analysis. JAMA Psychiatry, 77(7), 694–702. https://doi.org/10.1001/jamapsychiatry.2020.0164
Hengartner, M. P. (2020). How effective are antidepressants for depression over the long term? A critical review of relapse prevention trials and the issue of withdrawal confounding. Therapeutic Advances in Psychopharmacology, 10, 2045125320921694. https://doi.org/10.1177/2045125320921694
Leichsenring, F., & Leweke, F. (2017). Social Anxiety Disorder. New England Journal of Medicine, 376(23), 2255–2264. https://doi.org/10.1056/NEJMcp1614701
Rice, F., Riglin, L., Lomax, T., Souter, E., Potter, R., Smith, D. J., Thapar, A. K., & Thapar, A. (2019). Adolescent and adult differences in major depression symptom profiles. Journal of Affective Disorders, 243, 175–181. https://doi.org/10.1016/j.jad.2018.09.015
Sibley, M. H., Rohde, L. A., Swanson, J. M., Hechtman, L. T., Molina, B. S. G., Mitchell, J. T., Arnold, L. E., Caye, A., Kennedy, T. M., Roy, A., & Stehli, A. (2018). Late-Onset ADHD Reconsidered With Comprehensive Repeated Assessments Between Ages 10 and 25. American Journal of Psychiatry, 175(2), 140–149. https://doi.org/10.1176/appi.ajp.2017.17030298
Toussaint, A., Hüsing, P., Gumz, A., Wingenfeld, K., Härter, M., Schramm, E., & Löwe, B. (2020). Sensitivity to change and minimal clinically important difference of the 7-item Generalized Anxiety Disorder Questionnaire (GAD-7). Journal of Affective Disorders, 265, 395–401. https://doi.org/10.1016/j.jad.2020.01.032
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