Comprehensive Psychiatric Evaluation On Major Depressive Disorder Assignment

Comprehensive Psychiatric Evaluation On Major Depressive Disorder Assignment

NRNP PRAC 6645 Comprehensive Psychiatric Evaluation on Major Depressive Disorder or MDD

Subjective:

CC (chief complaint): The patient is a 45 year-old African American male presenting with complaints of insomnia, depressed mood or “feeling sad all day”, and ‘wanting to just close myself indoors all the time”. He has been having the symptoms for the past one and a half months.

HPI: The patient is a 45 year-old African American male who presents for evaluation with the above complaints. He denies a previous history of the presenting symptoms which he says began about 45 days ago. The duration of the symptoms has been constant since they started. He can no longer enjoy some of the activities that he enjoyed previously. The insomnia and the depressed mood are characteristically relentless and becoming worse by the day. The symptoms are aggravated by solitude but a bit relieved when he is with his family. The symptoms are present during the day and at night all through. When asked to rate the severity of his symptoms he gives a score of 6/10 Comprehensive Psychiatric Evaluation On Major Depressive Disorder Assignment.

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Past Psychiatric History:

General Statement: He has not had any psychiatric conditions before and does not even remember being treated for any mental condition. He is still functional for self but is slowly becoming dysfunctional on the vocational side since he has been missing work lately.
Caregivers: He does not require caregivers at the moment as he is still functional for self and can take care of himself.
Hospitalizations: He has never been hospitalized for a mental health condition. The ony admission was for a bout of nonalcoholic fatty iver disease or NAFLD.
Medication trials: He has never been put on any psychiatric medications.
Psychotherapy or Previous Psychiatric Diagnosis: He has never been diagnosed with a psychiatric condition or been on psychotherapy.

Substance Current Use and History: He denies smoking or using other illegal substances such as marijuana or cocaine. He however admits to drinking socially especially over the weekends with friends.

Family Psychiatric/ Substance Use History: There is no significant psychiatric history on his family’s side except for his maternal grandfather who had been treated for depression while still serving in the army. His father is a smoker and a drinker and is still alive. No one else in the family uses any substance.

Psychosocial History: He is a high school teacher at a local school and likes to go to the countryside for nature viewing and also swimming. He has been married for 18 years and as a daughter. He stays together with his family but the wife is a tracker and this has occasionally brought disagreements at the home. They live in a neighborhood that has all the necessary amenities such as clean drinking water and a service for garbage collection. In the house there is a smoke detector system and a burglar alarm system. When driving he does not use his phone and always wears a seatbelt.

Medical History:

Current Medications: He has been regularly using over the counter melatonex 3 mg for his sleeplessness.
Allergies: He has no known allergies.

Reproductive Hx: He describes himself as a heterosexual male and is married with one child.

Review of Systems (ROS)

GENERAL: Denies fever, chills, or weight loss. POSITIVE for fatigue.
HEENT: Negative for diplopia, photophobia, tinnitus, otorrhea, rhinorrhea, sneezing, difficulty swallowing and sore throat.
SKIN: Denies rashes, itching, or eczema.
CARDIOVASCULAR: Denies chest pains or chest tightness and edema.
RESPIRATORY: Denies shortness of breath and coughing.
GASTROINTESTINAL: Denies diarrhea, vomiting, or nausea.
GENITOURINARY: Denies frequency of micturition, dysuria, or hesitancy.
NEUROLOGICAL: Negative for syncope, dizziness,
MUSCULOSKELETAL: Denies joint pains, muscle pain, or back pain.
HEMATOLOGIC: Denies a history of clotting or bood disorders.
LYMPHATICS: Negative for lymphadenopathy and splenectomy.
ENDOCRINOLOGIC: Denies previous hormonal therapy, excessive thirst, excessive drinking of water, cold intolerance, or heat intolerance (2017, Carlat)Comprehensive Psychiatric Evaluation On Major Depressive Disorder Assignment.

Objective:

Vital signs: 140/95 mmHg (normal cuff sitting), 82 b/m, 16 breaths/ min, 98.7°F; BMI 30.5 kg/m² (obese)

Diagnostic results:

Normal WBC count with no leucocytosis noted.
CT scan of the head shows no abnormalities.
The Beck Depression Inventory II or BDI-II is positive with a score of 25. This means that he has moderate depression.

Assessment:

Mental Status Examination: The client is a 45-year-old African-American male who looks attentive and aware of his surroundings, including place, space, person, event, and time. During the examination, he stands normally and is pleasant. His attire is appropriate for the event and the climate. However, eye contact is poor, and there is some evidence of psychomotor retardation. His speech is straightforward, succinct, and to the point. His speech tempo is lagging and his rhythm is monotonous. On the other side, the loudness is low and minimal. He has no distinguishing mannerisms, gestures, or tics. His self-reported mood is “sad,” and his affect is dysphoric. As a result, the two are congruent. He has no hallucinations or delusions and denies having homicidal ideas, though he admits to having suicide ideas. His insight and judgment are intact and he acknowledges that he is sick and needs treatment. The diagnosis is Major depressive disorder (MDD) with the DSM-5 diagnostic code of 296.22. (F32.1).

Differential Diagnoses:

Major Depressive Disorder or MDD: 296.22 (F32.1): The diagnosis for this patient is major depressive disorder or MDD. His symptoms are moderate as indicated by the BDI-II score (APA, 2013; Sadock et al., 2015). Since the onset of the manifestations 45 days ago, the symptoms have been present all the time all day and night. They meet the DSM-5 diagnostic criteria for MDD (APA, 2013; Sadock et al., 2015).
Dysthymia or Persistent Depressive Disorder: 300.4 (F34.1): The patient’s second most likely differential diagnosis is dysthymia, also known as persistent depressive disorder (APA, 2013; Sadock et al., 2015). The DSM-5 diagnostic criteria for it include being depressed for most of the day almost all of the time, as well as experiencing two or more specific complaints while depressed. Insomnia, fatigue, low self-esteem, appetite loss, and reduced focus are among the symptoms. Furthermore, another psychological issue does not fully explain the patient’s condition (APA, 2013; Sadock et al., 2015).
Bipolar Disorder: 296.52 (F31.32): The DSM-5 diagnostic criteria for bipolar disorder must be met, which include a period of continuously elevated arousal with specific symptoms. Distractibility, insomnia, and exaggerated self-esteem are among the symptoms. Significant deterioration is caused by a psychological disease that is not the result of a drug addiction or another physical ailment (APA, 2013; Sadock et al., 2015). Bipolar disorder is ranked third in importance because this patient fits some of these requirements but not all of them.

Reflections: And I would have to assess this 45-year-old again, I would follow the same steps I did the first time. Because I met all of the standards when examining the mentally ill patient (Carlat, 2017). I made assured that all bioethics requirements were met when I examined the client. Before his informed consent was obtained, he was informed of every procedure and therapy as required by autonomy. I kept my word, performed my best, and avoided doing anything which would annoy or offend him and breach nonmaleficence. Above everything, I interacted with him with extraordinary cultural awareness, eliminating any inquiries that would be perceived as disrespectful. Diversity exemplifies the ethical concept of justice (Haswell, 2019). I explained the need of going to all therapy sessions to him (Corey, 2017). The patient has a follow up date after four weeks for evaluation of treatment efficacy and response Comprehensive Psychiatric Evaluation On Major Depressive Disorder Assignment.

Case Formulation and Treatment Plan:

This is a classic case of major depressive disorder and the management will include both pharmacotherapy and psychotherapy as follows:

Sertraline (Zoloft) 100 mg orally every day (Stahl, 2017)
To continue with the melatonex for the insomnia

Cognitive behavioral therapy (CBT) for eight weeks (Corey, 2017)

Family therapy together with his wife
Referral to a dietician and a physical therapist for diet and exercise program for weight reduction
Review or follow up in 4 weeks.

References

American Psychiatric Association [APA] (2013). Diagnostic and Statistical Manual of Mental Disorders (DSM-5), 5^th ed. Author.

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

Corey, G. (2017). Theory and practice of counselling and psychotherapy, 10^th ed. Cengage Learning.

Haswell, N. (2019). The four ethical principles and their application in aesthetic practice. Journal of Aesthetic Nursing, 8(4), 177-179. https://doi.org/10.12968/joan.2019.8.4.177

Sadock, B.J., Sadock, V.A., & Ruiz, P. (2015). Synopsis of psychiatry: Behavioral sciences clinical psychiatry, 11^th ed. Wolters Kluwer.

Stahl, S.M. (2017). Stahl’s essential psychopharmacology: Prescriber’s guide, 6^th ed. Cambridge University Press.

Assignment 2: Comprehensive Psychiatric Evaluation Note and Patient Case Presentation

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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, you should include the complete comprehensive psychiatric evaluation note as a Word document and pdf/images of each page that is initialed and signed by your Preceptor. You must submit your note using SafeAssign.

Please Note: Electronic signatures are not accepted. If both files are not received by the due date, Faculty will deduct points per the Walden Grading Policy.

Then, based on your evaluation of this patient, develop a video presentation of the case. Plan your presentation using the Assignment rubric and rehearse what you plan to say. Be sure to review the Kaltura Media Uploader resource in the left-hand navigation of the classroom for help creating your self-recorded Kaltura video.

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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

Record yourself presenting the complex case for your clinical patient.

Do not sit and read your written evaluation! The video portion of the assignment is a simulation to demonstrate your ability to succinctly and effectively present a complex case to a colleague for a case consultation. The written portion of this assignment is a simulation for you to demonstrate to the faculty your ability to document the complex case as you would in an electronic medical record. The written portion of the assignment will be used as a guide for faculty to review your video to determine if you are omitting pertinent information or including non-essential information during your case staffing consultation vide Comprehensive Psychiatric Evaluation On Major Depressive Disorder Assignmento.

In your presentation:

Dress professionally and present yourself in a professional manner.

Display your photo ID at the start of the video when you introduce yourself.

Ensure that you do not include any information that violates the principles of HIPAA (i.e., don’t use the patient’s name or any other identifying information).

Present the full complex case study. Be succinct in your presentation, and do not exceed 8 minutes. 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 Comprehensive Psychiatric Evaluation On Major Depressive Disorder Assignment.