Case Study On Assessing and Diagnosing Patients With Mood Disorders

Case Study On Assessing and Diagnosing Patients With Mood Disorders

Introduction

A Subjective, Objective, Assessment, and Plan is among the most common forms of documentation used to input notes into the medicalrecords of a patient. This SOAP note will allow a provider to both record and share information about a psychiatric patient in an easy to read and systematic format. The patient in question has been diagnosed with depression in the past. However, this SOAP note will also provide differential diagnoses basedon the patient’s prevailing symptoms. The purpose of this SOAP note therefore is to provide a diagnosis for the patient thereby allowing the relevant health care practitioners to develop treatment plans that will ensure positive outcomes for the patient Case Study On Assessing and Diagnosing Patients With Mood Disorders.

PLACE YOUR ORDER HERE

Subjective:

CC (chief complaint): CL, an 18 year old patient states that she came to the clinic for her depression, irritability, aggression and impulsivity. The patient has been trying to manage her depression since the age of nine.

HPI: The patient was diagnosed with depression at the age of nine. She has history of treatment since age 9 for conduct disorder, depression, history of taking citalopram which worsened her irritability, aggression, impulsivity. She has been in a 90-day teen residential mental health facility discharged three months ago with lithium 300mg in am and 600mg at bedtime, aripiprazole 2.5mg in the morning. She has a history of domestic violence toward her older brother.

Past Psychiatric History:

• General Statement: The patient was diagnosed with depression at the age of 9.
• Caregivers (if applicable): The patient lives with her parents and grandmother from whom she is reported to have been stealing money to buy shoes, purses and clothes among other things.
• Hospitalizations: The patient has been in a 90-day teen residential mental health facility discharged three months ago.
• Medication trials: CL has prescriptions for lithium 300mg in the morning and 600mg at bedtime, aripiprazole 2.5mg in the morning.
• Psychotherapy or Previous Psychiatric Diagnosis: CL was diagnosed with depression at the age of 9 and experiences irritation, impulsivity and aggression.

Substance Current Use and History: CL tested positive for marijuana use before being admitted to the 90-day teen residential mental health facility and is believed to be hiding her medication by her parents.

Family Psychiatric/Substance Use History: The patient’s grandmother has a history of bipolar disorder while her maternal aunt and her biological mother have anxiety.

Psychosocial History: The patient reports that her appetite is ravishing. While she is not currently partnered, she reports she is bisexual and that lately, she is hyper-sexual reporting an increase of unprotected sex. She has a Nexplanon implant. The patient has history of self-harm with cutting but reports having last engaged in the behavior 6 months ago.

Medical History:

• Current Medications: The patient is on with lithium 300mg in am and 600mg at bedtime, aripiprazole 2.5mg in the morning.
• Allergies: CL reports no recorded allergies.

• Reproductive Hx: She has a Nexplanon implant and reports and increase in unprotected sex.

ROS:

• General: No fevers, No chills. No significant unintentional weight change, No change in exercise tolerance.
• Head: No headaches, No dizziness.
• Eyes: No acute vision changes/photophobia during HA, No eye pain, No redness, No and discharge.
• Ears: No change in hearing, No ear pain, No ear drainage.
• Nose: No epistaxis, No congestion.
• Mouth: No sore throat, No difficulty swallowing.
• Neck: No stiffness, No pain, No noted masses.
• Chest: No dyspnea, No wheezing.
• Skin: Patient with No complaints of rashes or lesions.
• Cardiovascular: No chest pains, No palpitations.
• Gastrointestinal: No change in appetite, No abdominal pains, No bowel habit changes, No emesis.
• Genitourinary: No urinary urgency, No dysuria, No change in nature of urine.
• Musculoskeletal: No pain in muscles or joints, No paresthesias or numbness.
• Neurologic: No weakness. No changes in sensation.
• Psychiatric: Experiences depressive symptoms, significant changes in sleep habits (only sleeps for 2 to 3 hours), Patient experiences thought of hurting self and others Case Study On Assessing and Diagnosing Patients With Mood Disorders.

Assessment:

Mental Status Examination:

• Appearance/behavior: The patient appeared energetic and hyperactive during her assessment.
• Speech/language: The patient’s speech was pressured and therefore difficult to interrupt. She was also emphatic and loud.
• Mood/Affect: The patient was expansive. She also displayed a low tolerance for frustration.
• Thought Process: The patient displayed a fight of ideas often shifting from topic to topic after a continuous flow of accelerated speech.
• Perpetual Disturbances: Patient displayed some paranoid features.

Differential Diagnoses:

• Major Depressive disorder
• Bipolar Disorder
• Borderline Personality Disorder

Reflections:

The patient appears to be suffering from bipolar disorder. This conclusion is supported by not only her symptoms but the fact that her grandmother was diagnosed with the same. Bipolar disorder is a relatively common psychiatric disorder that is characterized by cognitive deficits and affective instability especially when a person is going through mood episodes. According to Masso Rodriguez, et al., (2021), one of the main differences between people with bipolar disorder and those with borderline personality disorder is that the former will tend to experience both depression and mania while the latter experience feelings of desperation, emptiness, anger, loneliness, hopelessness and also intense emotional pain.

References

Masso Rodriguez, A., Hogg, B., Gardoki-Souto, I., Valiente-Gómez, A., Trabsa, A., Mosquera, D., … & Amann, B. L. (2021). Clinical Features, Neuropsychology and Neuroimaging in Bipolar and Borderline Personality Disorder: A Systematic Review of Cross-Diagnostic Studies. Frontiers in psychiatry, 12, 895.

Assignment: Assessing and Diagnosing Patients With Mood Disorders

Photo Credit: Juanmonino / E+ / Getty Images

Accurately diagnosing depressive disorders can be challenging given their periodic and, at times, cyclic nature. Some of these disorders occur in response to stressors and, depending on the cultural history of the client, may affect their decision to seek treatment. Bipolar disorders can also be difficult to properly diagnose. While clients with a bipolar or related disorder will likely have to contend with the disorder indefinitely, many find that the use of medication and evidence-based treatments have favorable outcomes.

To Prepare:

• 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.
• 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.
• 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. Psychiatric & Medical Diagnoses

By Day 7 of Week 3

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 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.).

 

Further questions to answer: How you would you approach your assessment? Would you ask to include family members for collateral information? What tests or assessments would you order or conduct? Are there any referrals from which your patient could benefit? How would you promote overall health and disease prevention?

 

Resources

Sadock, B. J., Sadock, V. A., and Ruiz, P. (2015). Kaplan & Sadock’s synopsis of psychiatry (11th ed.). Wolters Kluwer.

• Chapter 9, Anxiety Disorders
• Chapter 10, Obsessive-Compulsive and Related Disorders
• Chapter 11, Trauma- and Stressor-Related Disorders
• Chapter 31.11 Trauma-Stressor Related Disorders in Children
• Chapter 31.13 Anxiety Disorders in Infancy, Childhood, and Adolescence
• Chapter 31.14 Obsessive-Compulsive Disorder in Childhood and Adolescence

Case Study

 

Name: Ms. Cheyenne Lisenbe

Gender: female

Age:18 years old

T- 97.4 P- 94 R 22 136/86 Ht 5’2 Wt 121

Background: Currently living with her parents in Locust Grove, Oklahoma along with two

younger sisters and 1 older brother. She is a senior in high school, not currently partnered,

reports she is bisexual, lately hyper-sexual reporting increase of unprotected sex. She has been

stealing money out of her grandmother’s purse to buy clothes, shoes, purses, “and just other

things. She has history of treatment since age 9 for conduct disorder, depression, history of

taking citalopram which worsened her irritability, aggression, impulsivity. She has been in a 90-

day teen residential mental health facility discharged three months ago with lithium 300mg in am

and 600mg at bedtime, aripiprazole 2.5mg in the morning. When discharged, her labs were

within normal ranges and urine toxicology negative. She was positive for cannabis upon

admission. Her parents believe she is hiding her medication as she has made comments “they

slow me down; they make me not think fast” She has hx of domestic violence toward her older

brother with juvenile assault charge. No current legal issues. Her grandmother has hx of bipolar

disorder; her mother and her maternal aunt have anxiety. She is sleeping 2-3hrs/24 hrs. Reports

her appetite “ravishing.” She has no medical issues; has Nexplanon implant; hx of self-harm with

cutting, last engaged in the behavior 6 months ago.

Symptom Media. (Producer). (2018). Training title 150 [Video]. https://video-alexanderstreetcom.ezp.waldenulibrary.org/watch/training-title-150

 

Instructions

Fill out the attached template in its entirety using the case study and video for more information. See RUBRIC attached as well as exemplar template. Complete all the tabs in the review of systems on the template. Use 4 pages to complete this template. Provide at least references dated within the last 5 years APA 7^th edition format. Give an introduction, purpose, and conclusion.

Rubric Detail

 

Select Grid View or List View to change the rubric’s layout.

Name: NRNP_6635_Week4_Assignment_Rubric

• Grid View
• List View

		Excellent	Good	Fair	Poor
Create documentation in the Comprehensive Psychiatric Evaluation Template about the patient you selected. In the Subjective section, provide: • Chief complaint • History of present illness (HPI) • Past psychiatric history • Medication trials and current medications • Psychotherapy or previous psychiatric diagnosis • Pertinent substance use, family psychiatric/substance use, social, and medical history • Allergies • ROS		18 (18%) – 20 (20%) The response throughly and accurately describes the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis.	16 (16%) – 17 (17%) The response accurately describes the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis.	14 (14%) – 15 (15%) The response describes the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis, but is somewhat vague or contains minor innacuracies.	0 (0%) – 13 (13%) The response provides an incomplete or inaccurate description of the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis. Or, subjective documentation is missing.
In the Objective section, provide: • Physical exam documentation of systems pertinent to the chief complaint, HPI, and history • Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses.		18 (18%) – 20 (20%) The response thoroughly and accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are thoroughly and accurately documented.	16 (16%) – 17 (17%) The response accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are accurately documented.	14 (14%) – 15 (15%) Documentation of the patient’s physical exam is somewhat vague or contains minor innacuracies. Diagnostic tests and their results are documented but contain minor innacuracies.	0 (0%) – 13 (13%) The response provides incomplete or inaccurate documentation of the patient’s physical exam. Systems may have been unnecessarily reviewed, or, objective documentation is missing.
In the Assessment section, provide: • Results of the mental status examination, presented in paragraph form. • At least three differentials with supporting evidence. List them from top priority to least priority. Compare the DSM-5-TR diagnostic criteria for each differential diagnosis and explain what DSM-5-TR 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.		23 (23%) – 25 (25%) The response thoroughly and accurately documents the results of the mental status exam. Response lists at least three distinctly different and detailed possible disorders in order of priority for a differential diagnosis of the patient in the assigned case study, and it provides a thorough, accurate, and detailed justification for each of the disorders selected.	20 (20%) – 22 (22%) The response accurately documents the results of the mental status exam. Response lists at least three distinctly different and detailed possible disorders in order of priority for a differential diagnosis of the patient in the assigned case study, and it provides an accurate justification for each of the disorders selected.	18 (18%) – 19 (19%) The response documents the results of the mental status exam with some vagueness or innacuracy. Response lists at least three different possible disorders for a differential diagnosis of the patient and provides a justification for each, but may contain some vaguess or innacuracy.	0 (0%) – 17 (17%) The response provides an incomplete or inaccurate description of the results of the mental status exam and explanation of the differential diagnoses. Or, assessment documentation is missing.
Reflect on this case. Discuss what you learned and what you might do differently. Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), social determinates of health, 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.).		9 (9%) – 10 (10%) Reflections are thorough, thoughtful, and demonstrate critical thinking.	8 (8%) – 8 (8%) Reflections demonstrate critical thinking.	7 (7%) – 7 (7%) Reflections are somewhat general or do not demonstrate critical thinking.	0 (0%) – 6 (6%) Reflections are incomplete, inaccurate, or missing.
Provide at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support your diagnostics and differential diagnoses. Be sure they are current (no more than 5 years old).		14 (14%) – 15 (15%) The response provides at least three current, evidence-based resources from the literature to support the assessment and diagnosis of the patient in the assigned case study. The resources reflect the latest clinical guidelines and provide strong justification for decision making.	12 (12%) – 13 (13%) The response provides at least three current, evidence-based resources from the literature that appropriately support the assessment and diagnosis of the patient in the assigned case study.	11 (11%) – 11 (11%) Three evidence-based resources are provided to support assessment and diagnosis of the patient in the assigned case study, but they may only provide vague or weak justification.	0 (0%) – 10 (10%) Two or fewer resources are provided to support assessment and diagnosis decisions. The resources may not be current or evidence based.
Written Expression and Formatting—Paragraph development and organization: Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused—neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria.		5 (5%) – 5 (5%) A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria. Paragraphs and sentences follow writing standards for flow, continuity, and clarity.	4 (4%) – 4 (4%) Purpose, introduction, and conclusion of the assignment are stated, yet they are brief and not descriptive. Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time.	3.5 (3.5%) – 3.5 (3.5%) Purpose, introduction, and conclusion of the assignment is vague or off topic. Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%-79% of the time.	0 (0%) – 3 (3%) No purpose statement, introduction, or conclusion were provided. Paragraphs and sentences follow writing standards for flow, continuity, and clarity less than 60% of the time.
Written Expression and Formatting—English writing standards: Correct grammar, mechanics, and punctuation		5 (5%) – 5 (5%) Uses correct grammar, spelling, and punctuation with no errors	4 (4%) – 4 (4%) Contains a few (one or two) grammar, spelling, and punctuation errors	3 (3%) – 3 (3%) Contains several (three or four) grammar, spelling, and punctuation errors	0 (0%) – 2 (2%) Contains many (≥ five) grammar, spelling, and punctuation errors that interfere with the reader’s understanding
Total Points: 100

Name: NRNP_6635_Week4_Assignment_Rubric

INSTRUCTIONS ON HOW TO USE EXEMPLAR AND TEMPLATE—READ CAREFULLY

If you are struggling with the format or remembering what to include, follow the Comprehensive Psychiatric Evaluation Template AND the Rubric as your guide. It is also helpful to review the rubric in detail in order not to lose points unnecessarily because you missed something required. Below highlights by category are taken directly from the grading rubric for the assignment in Weeks 4–10. After reviewing the full details of the rubric, you can use it as a guide Case Study On Assessing and Diagnosing Patients With Mood Disorders.

ORDER A PLAGIARISM FREE PAPER NOW

In the Subjective section, provide:

• Chief complaint
• History of present illness (HPI)
• Past psychiatric history
• Medication trials and current medications
• Psychotherapy or previous psychiatric diagnosis
• Pertinent substance use, family psychiatric/substance use, social, and medical history
• Allergies
• ROS
• Read rating descriptions to see the grading standards!

In the Objective section, provide:

• Physical exam documentation of systems pertinent to the chief complaint, HPI, and history
• Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses.
• Read rating descriptions to see the grading standards!

In the Assessment section, provide:

• Results of the mental status examination, presented in paragraph form.
• At least three differentials with supporting evidence. List them from top priority to least priority. Compare the DSM-5-TR diagnostic criteria for each differential diagnosis and explain what DSM-5-TR 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.
• Read rating descriptions to see the grading standards!

Reflect on this case. Include: Discuss what you learned and what you might do differently. Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), social determinates of health, 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.).

(The comprehensive evaluation is typically the initial new patient evaluation. You will practice writing this type of note in this course. You will be ruling out other mental illnesses so often you will write up what symptoms are present and what symptoms are not present from illnesses to demonstrate you have indeed assessed for all illnesses which could be impacting your patient. For example, anxiety symptoms, depressive symptoms, bipolar symptoms, psychosis symptoms, substance use, etc.)

EXEMPLAR BEGINS HERE

CC (chief complaint): A brief statement identifying why the patient is here. This statement is verbatim of the patient’s own words about why presenting for assessment. For a patient with dementia or other cognitive deficits, this statement can be obtained from a family member.

HPI: Begin this section with patient’s initials, age, race, gender, purpose of evaluation, current medication and referral reason. For example:

N.M. is a 34-year-old Asian male presents for psychiatric evaluation for anxiety. He is currently prescribed sertraline which he finds ineffective. His PCP referred him for evaluation and treatment.

Or

P.H., a 16-year-old Hispanic female, presents for psychiatric evaluation for concentration difficulty. She is not currently prescribed psychotropic medications. She is referred by her therapist for medication evaluation and treatment.

Then, this section continues with the symptom analysis for your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis.

Paint a picture of what is wrong with the patient. First what is bringing the patient to your evaluation.  Then, include a PSYCHIATRIC REVIEW OF SYMPTOMS.  The symptoms onset, duration, frequency, severity, and impact. Your description here will guide your differential diagnoses. You are seeking symptoms that may align with many DSM-5-TR diagnoses, narrowing to what aligns with diagnostic criteria for mental health and substance use disorders.

Past Psychiatric History: This section documents the patient’s past treatments. Use the mnemonic Go Cha MP. 

General Statement: Typically, this is a statement of the patients first treatment experience. For example: The patient entered treatment at the age of 10 with counseling for depression during her parents’ divorce. OR The patient entered treatment for detox at age 26 after abusing alcohol since age 13.

Caregivers are listed if applicable.

Hospitalizations: How many hospitalizations? When and where was last hospitalization? How many detox? How many residential treatments? When and where was last detox/residential treatment? Any history of suicidal or homicidal behaviors? Any history of self-harm behaviors?

Medication trials: What are the previous psychotropic medications the patient has tried and what was their reaction? Effective, Not Effective, Adverse Reaction? Some examples: Haloperidol (dystonic reaction), risperidone (hyperprolactinemia), olanzapine (effective, insurance wouldn’t pay for it)

Psychotherapy or Previous Psychiatric Diagnosis: This section can be completed one of two ways depending on what you want to capture to support the evaluation. First, does the patient know what type? Did they find psychotherapy helpful or not? Why? Second, what are the previous diagnosis for the client noted from previous treatments and other providers. Thirdly, you could document both.

Substance Use History: This section contains any history or current use of caffeine, nicotine, illicit substance (including marijuana), and alcohol. Include the daily amount of use and last known use. Include type of use such as inhales, snorts, IV, etc. Include any histories of withdrawal complications from tremors, Delirium Tremens, or seizures.

Family Psychiatric/Substance Use History: This section contains any family history of psychiatric illness, substance use illnesses, and family suicides. You may choose to use a genogram to depict this information. Be sure to include a reader’s key to your genogram or write up in narrative form.

Social History: This section may be lengthy if completing an evaluation for psychotherapy or shorter if completing an evaluation for psychopharmacology.  However, at a minimum, please include:

Where patient was born, who raised the patient

Number of brothers/sisters (what order is the patient within siblings)

Who the patient currently lives with in a home? Are they single, married, divorced, widowed? How many children?

Educational Level

Hobbies:

Work History: currently working/profession, disabled, unemployed, retired?

Legal history: past hx, any current issues?

Trauma history: Any childhood or adult history of trauma?

Violence Hx: Concern or issues about safety (personal, home, community, sexual (current & historical)

Medical History: This section contains any illnesses, surgeries, include any hx of seizures, head injuries.

 

Current Medications: Include dosage, frequency, length of time used, and reason for use. Also include OTC or homeopathic products.

Allergies: Include medication, food, and environmental allergies separately. Provide a description of what the allergy is (e.g., angioedema, anaphylaxis). This will help determine a true reaction vs. intolerance.

Reproductive Hx: Menstrual history (date of LMP), Pregnant (yes or no), Nursing/lactating (yes or no), contraceptive use (method used), types of intercourse:  oral, anal, vaginal, other, any sexual concerns

ROS: Cover all body systems that may help you include or rule out a differential diagnosis.  Please note: THIS IS DIFFERENT from a physical examination!

You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe Case Study On Assessing and Diagnosing Patients With Mood Disorders.

Example of Complete ROS:

GENERAL: No weight loss, fever, chills, weakness, or fatigue.

HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.

SKIN: No rash or itching.

CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.

RESPIRATORY: No shortness of breath, cough, or sputum.

GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.

GENITOURINARY: Burning on urination, urgency, hesitancy, odor, odd color

NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness.

HEMATOLOGIC: No anemia, bleeding, or bruising.

LYMPHATICS: No enlarged nodes. No history of splenectomy.

ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.

Physical exam (If applicable and if you have opportunity to perform—document if exam is completed by PCP): From head to toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head-to-toe format i.e., General: Head: EENT: etc.

Diagnostic results: Include any labs, X-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines).

Assessment

Mental Status Examination: For the purposes of your courses, this section must be presented in paragraph form and not use of a checklist! This section you will describe the patient’s appearance, attitude, behavior, mood and affect, speech, thought processes, thought content, perceptions (hallucinations, pseudohallucinations, illusions, etc.)., cognition, insight, judgment, and SI/HI. See an example below. You will modify to include the specifics for your patient on the above elements—DO NOT just copy the example. You may use a preceptor’s way of organizing the information if the MSE is in paragraph form.

He is an 8-year-old African American male who looks his stated age. He is cooperative with examiner. He is neatly groomed and clean, dressed appropriately. There is no evidence of any abnormal motor activity. His speech is clear, coherent, normal in volume and tone. His thought process is goal directed and logical. There is no evidence of looseness of association or flight of ideas. His mood is euthymic, and his affect appropriate to his mood. He was smiling at times in an appropriate manner. He denies any auditory or visual hallucinations. There is no evidence of any delusional thinking.   He denies any current suicidal or homicidal ideation. Cognitively, he is alert and oriented. His recent and remote memory is intact. His concentration is good. His insight is good.

Differential Diagnoses: You must have at least three differentials with supporting evidence. Explain what rules each differential in or out and justify your primary diagnostic impression selection. You will use supporting evidence from the literature to support your rationale. Include pertinent positives and pertinent negatives for the specific patient case.

 

Also included in this section is the reflection. Reflect on this case and discuss whether or not you agree with your preceptor’s assessment and diagnostic impression of the patient and why or why not. What did you learn from this case? What would you do differently?

Also include in your reflection a discussion related to legal/ethical considerations (demonstrating critical thinking beyond confidentiality and consent for treatment!), social determinates of health, 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.).

References (move to begin on next page)

You are required to include at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines which relate to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting Case Study On Assessing and Diagnosing Patients With Mood Disorders.