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Comprehensive Psychiatric Evaluation Note On Client With Mood Disorder In Group Psychotherapy Assignment

Comprehensive Psychiatric Evaluation Note On Client With Mood Disorder In Group Psychotherapy Assignment

Subjective:

CC (chief complaint): “My parents force to me to go to school but I don’t feel like attending classes anymore”

HPI: B.T is a Caucasian male who is 23 years old and exhibits symptoms of a depressed mood. He claims that he does not want to attend his classes, but his parents continue to force him to go. He previously took medicine to improve his mood, but he decided to quit taking it one month ago since it was not helping him feel better. He also reports using marijuana in an effort to improve his mood. Because of his conduct, his parents felt they had no choice but to check him into a psychiatric institution. The patient reports that he knows he is supposed to be attending classes but does not feel like it Comprehensive Psychiatric Evaluation Note On Client With Mood Disorder In Group Psychotherapy Assignment.

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Past Psychiatric History:

  • General Statement: Diagnosed with depression one year ago.
  • Caregivers (if applicable): The patients parents are his caregivers
  • Hospitalizations: Denies history of hospitalizations
  • Medication trials: The patient has used Zoloft and Risperidone in the past but stopped taking one month ago.
  • Psychotherapy or Previous Psychiatric Diagnosis: Depression

Substance Current Use and History: Reports daily use of marijuana. Denies tobacco, alcohol or other illicit drugs use.

Family Psychiatric/Substance Use History: Paternal grandfather had Alzheimer’s disease. No family history of substance use.

Psychosocial History: The patient is the first born with two siblings. He is a student at a local college where he is majoring in community development. He reports current disinterest in attending college. He is completely reliant on both of his parents for financial support. He lives with his parents and siblings in a rented apartment. He claims that playing basketball, going to the gym, and swimming were formerly his hobbies, but he is no longer interested in any of these activities.

Medical History:

 

  • Current Medications: Zoloft 50mg once daily. Escitalopram 10mg once daily.
  • Allergies: NKA
  • Reproductive Hx: Heterosexual. Currently not sexually active.

Objective:

Diagnostic results: ECG-normal. MRI-normal. According to the results, the patient did not have any issues with their brain or heart.

Assessment:

Mental Status Examination:

B.T. seems to be in a depressed mood. He appears well-dressed, well-groomed and well-nourished. He is cooperative and is not evasive to certain questions During the interview, he keeps his eyes cast downward and does not face the practitioner when he is speaking. He is alert and oriented to person, place, time and situation, but her attention span is limited. Her articulation appears to be intact. Her speech is clear and coherent, without contradiction. The patient is exhibiting symptoms of sadness and a restricted affect. He is not happy that he does not feel like going to school and at the same time is not happy that his parents are forcing him to go to school. He denies any suicidal or homicidal thoughts. There are no psychotic symptoms, delusions, or hallucinations. His reasoning on various issues is logical. He displays good judgement and he is aware of his health situation Comprehensive Psychiatric Evaluation Note On Client With Mood Disorder In Group Psychotherapy Assignment.

Differential Diagnoses:

Major depressive disorder (F33.1): This is a mental disorder defined by an ongoing low mood or a lack of interest in activities. It may significantly impede one’s ability to function in day-to-day life (Christensen et al, 2020). This is most likely to be primary diagnosis for patient B.T because he is currently experiencing sadness and disinterest in attending his college classes.

Persistent depressive disorder (F34): This is a mild kind of depression that lasts for a long time. It is characterized by a depressed mood that lasts for at least two years and is accompanied by at least two additional symptoms of depression (Nübel et al., 2020). One may experience a loss of interest in typical day-to-day tasks, a sense of hopelessness, a lack of productivity, poor self-esteem, and an overarching sense of inferiority. The fact that the patient has been experiencing a depressed mood, hopelessness and lack of of interest in typical activities points to this condition as a possible diagnosis.

Bipolar disorder (F31): This is a condition that may cause periods of a wide range of emotions, including lows associated with depression and highs associated with manic behavior (Bobo & William, 2017). Mood swings might be an occasional occurrence or they can happen on a frequent basis throughout the year. Although the patient has had depressive mood, which is a clinical sign of bipolar illness, the fact that he has not experienced any manic behavior rules out the possibility that he suffers from this disorder.

 

Reflections:

When looking about this scenario, it is worth noting that several individuals suffer from depression, despite the fact that they seem to be doing well. B.T appears well-dressed and presents the appearance of a normal person, but  presents with a depressive mood. In order for him to overcome his depressed mood, he needs psychiatric help. When dealing with a situation such as this one, maintaining strict confidentiality is an ethical issue that might surface. B.T admits to engaging in the use of marijuana, which is a criminal offense. He risks going to prison if this information is revealed. As such, when evaluating and treating patients, protecting their confidentiality is of utmost importance Comprehensive Psychiatric Evaluation Note On Client With Mood Disorder In Group Psychotherapy Assignment.

Case Formulation and Treatment Plan:

The most appropriate therapeutic option for B.T. will be outpatient care. B.T. needs to see a therapist twice a week. He  needs to be referred to a local counselor who can assist him in dealing with his depressive mood. Additionally, the counselor will assist B.T in returning to his usual life. Web-based materials pertaining to mental health as well as connections for counselors are the essential resources for this patient. Cognitive-behavioral therapy will be the best psychotherapy technique for this patient. According to Sauer-Zavala et al. (2020), cognitive behavioral therapy will assist the patient in regaining control of his thoughts and enabling him to react to them in a manner that is more effective.

COMPREHENSIVE EVALUATION: of Group Therapy Client with Mood Disorder. Template and rubric attached

Learning Resources
Required Readings (click to expand/reduce)

American Group Psychotherapy Association. (2007–2020). Practice guidelines for group psychotherapy. https://www.agpa.org/home/practice-resources/practice-guidelines-for-group-psychotherapy

American Psychiatric Association. (2020). Clinical practice guidelines. https://psychiatryonline.org/guidelines

Carlat, D. J. (2017). The psychiatric interview (4th ed.). Wolters Kluwer.

Chapter 23, “Assessing Mood Disorders I: Depressive Disorders”
Chapter 24, “Assessing Mood Disorders II: Bipolar Disorders”

Week4 Assignment 2: Comprehensive Psychiatric Evaluation Note on Client with Mood Disorder in Group Psychotherapy (to be used for Patient Case Presentation video) Template Attached

Psychiatric notes are a way to reflect on your practicum experiences and connect them to the didactic learning you gain from your NRNP courses. Comprehensive psychiatric evaluation notes, such as the ones required in this practicum course, are often used in clinical settings to document patient care.

For this Assignment, you will document information about a patient that you examined in a group setting during the last 4 weeks, using the Comprehensive Psychiatric Evaluation Note Template provided. You will then use this note to develop and record a case presentation for this patient.

To Prepare
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 disorder during 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, and each page must be initialed by your Preceptor. When you submit your note,
Include at least five scholarly resources to support your assessment and diagnostic reasoning.
Ensure that you have the appropriate lighting and equipment to record the presentation.
The Assignment.

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Include subjective and objective data; assessment from most recent mental status exam; current psychiatric diagnosis including differentials that were ruled out; current psychotherapeutic plan (include one health promotion activity and one patient education strategy you provided); and patient progress toward treatment goals.

Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What was 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 in order of highest to lowest priority and explain why you chose them. What was your primary diagnosis and why? Describe how your primary diagnosis aligns with DSM-5-TR diagnostic criteria and is supported by the patient’s symptoms.

Plan: Describe your treatment modality and your plan for psychotherapy. Explain the principles of psychotherapy that underline your chosen treatment plan to support your rationale for the chosen psychotherapy framework. What were your follow-up plan and parameters? What referrals would you make or recommend as a result of this psychotherapy session?

Reflection notes: What would you do differently in a similar patient evaluation? Reflect on one social determinant of health according to the 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 consideration for this patient for improving health disparities and inequities in the realm of psychiatry and mental health? Demonstrate your critical thinking.

 References

Bobo, William V. (2017). The Diagnosis and Management of Bipolar I and II Disorders. Mayo Clinic Proceedings, (), S002561961730544X. https://doi.org/10.1016/j.mayocp.2017.06.022

Christensen, M. C., Wong, C. M., & Baune, B. T. (2020). Symptoms of major depressive disorder and their impact on psychosocial functioning in the different phases of the disease: Do the perspectives of patients and healthcare providers differ? Frontiers in Psychiatry, 11. https://doi.org/10.3389/fpsyt.2020.00280

Nübel, J., Guhn, A., Müllender, S., Le, H. D., Cohrdes, C., & Köhler, S. (2020). Persistent depressive disorder across the adult lifespan: Results from clinical and population-based surveys in Germany. BMC Psychiatry, 20(1). https://doi.org/10.1186/s12888-020-2460-5

Sauer‐Zavala, S., Southward, M. W., & Semcho, S. A. (2020). Integrating and differentiating personality and psychopathology in cognitive behavioral therapy. Journal of Personality, 90(1),89-102 Comprehensive Psychiatric Evaluation Note On Client With Mood Disorder In Group Psychotherapy Assignment.