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Comprehensive Psychiatric Evaluation On Major Depressive Disorder Assignment

Comprehensive Psychiatric Evaluation On Major Depressive Disorder Assignment

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.  Comprehensive Psychiatric Evaluation On Major Depressive Disorder Assignment

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)Comprehensive Psychiatric Evaluation On Major Depressive Disorder Assignment.

Differential Diagnoses:

  1. 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).
  2. 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)Comprehensive Psychiatric Evaluation On Major Depressive Disorder Assignment.
  3. 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)Comprehensive Psychiatric Evaluation On Major Depressive Disorder Assignment. The patient has a follow up date after four weeks for evaluation of treatment efficacy and response.

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:

  1. Sertraline (Zoloft) 100 mg orally every day (Stahl, 2017)
  2. To continue with the melatonex for the insomnia
  • Cognitive behavioral therapy (CBT) for eight weeks (Corey, 2017)
  1. Family therapy together with his wife
  2. Referral to a dietician and a physical therapist for diet and exercise program for weight reduction
  3. Review or follow up in 4 weeks.

References

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

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

Corey, G. (2017). Theory and practice of counselling and psychotherapy, 10th 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 Comprehensive Psychiatric Evaluation On Major Depressive Disorder Assignment

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

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

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Instructions and template uploaded. I need to be able to do a video presentation from this assignment. It has to be a mood disorder, so major depressive disorder would work if you could make something up. Also, need two other diagnosis it could be that was ruled out Comprehensive Psychiatric Evaluation On Major Depressive Disorder Assignment