Comprehensive Evaluation Of Depression Assignment

A. 8 Pages —Develop a log of patient encounters You must record at least 80 encounters with patients (40 children/adolescents and 40 adult/older adult).

The patient log must include the following:

Client Information
Visit Information
Practice Management
Diagnosis
Treatment Plan and Notes: You must include a brief summary/synopsis of the patient visit. This does not need to be a SOAP note, however the note needs to be sufficient to remember your patient encounter.

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See below for Sample with minimum amount of information that is required for each patient :1 CN/21/F Anxiety, changes in sleep patterns, and anxiety, HAM-A positive for
anxiety. DX Generalized anxiety disorder, (GAD). Paroxetine (Paxil) , psychotherapy Comprehensive Evaluation Of Depression Assignment

2 VM/48/F Hearing voices and people wanting to kill him. Auditory
hallucinations and persecutory delusions Schizophrenia – Medications- Paliperidone (Invega
Sustenna)
– Individual therapy

B. Write a comprehensive psychiatric evaluation on three of the patients from your log using the attached template from a previous class .
Each comprehensive psychiatric evaluation should have at least 5 resources and should be 6 pages long
18 pages total.

Subjective:

CC (chief complaint): “I have been experiencing tiredness, loss of interest in daily activities, and overeating”

HPI: JK, is a 42 year old female who presents with symptoms of depression, including depressed mood, loss of interest in activities, changes in appetite, difficulty with daily tasks, and feelings of hopelessness. She reports that her symptoms have been present for the past two months, and that they have been interfering with her ability to work and maintain relationships. The patient also reports a family history of depression and a recent significant life stressor in the form of losing her job. She denies any history of suicide attempts or self-harm. The patient is currently not receiving any treatment for her symptoms. She lives alone and reports having a good relationship with her sister, but does not have any close friends or romantic partners. She engages in occasional alcohol use, but denies any use of illicit drugs. Comprehensive Evaluation Of Depression Assignment

Past Psychiatric History: No past psychiatric illness.

General Statement: JK is a 42 year old who has been experiencing tiredness, loss of interest in daily activities, and overeating for the past one year.
Caregivers (if applicable): N/A
Hospitalizations: No history of hospitalizations
Medication trials: She has not been on any pharmacological agent.

Psychotherapy or Previous Psychiatric Diagnosis: No previous psychiatric diagnosis

Substance Current Use and History: The patient reports no current use of alcohol or recreational drugs. She also denies any history of substance abuse or dependence. She states that she occasionally drinks alcohol, but only in moderation and never to the point of intoxication. She has not used any recreational drugs in the past. She reports no history of treatment for substance abuse or dependence.

Family Psychiatric/Substance Use History: Patient reports that her mother was diagnosed with depression at age 50. Denies family history of substance use.

Psychosocial History: The patient currently lives alone in a one-bedroom apartment and is unemployed. She has completed some college coursework but does not have a degree. She is not currently married or in a domestic partnership. She reports having a good support system in the form of her sister, but has experienced a significant life stressor in the form of losing her job. The patient also engages in occasional alcohol use. Comprehensive Evaluation Of Depression Assignment

Medical History: She denies any medical history.

Current Medications: None
Allergies: No known food or drug allergies.
Reproductive Hx: Patient states that she had her first onset at the age of 15 and she has regular menstrual frequency. She denies any complications.

Objective:

Diagnostic results:

Physical exam: no abnormalities detected.

Laboratory tests: no abnormalities detected.

Psychological assessment: patient meets criteria for major depressive disorder based on a structured clinical interview.

Cognitive testing: patient shows mild deficits in attention and concentration, but no significant cognitive impairments. Comprehensive Evaluation Of Depression Assignment

Neuroimaging: no abnormalities detected on structural MRI.

Assessment:

Appearance: patient is well-groomed and neatly dressed. She appears her stated age and is of average weight and height.

Affect: patient’s mood appears to be congruent with her reported feelings of sadness and hopelessness. She has a flat affect, with minimal facial expressions and a monotonous tone of voice.

Behavior: patient is sitting in the chair with good posture and makes good eye contact. She answers questions in a clear and coherent manner.

Mood: patient reports feeling sad and hopeless most of the time. She reports a lack of interest in activities that she used to enjoy.

Thought processes: patient reports having negative thoughts about herself and her future. She denies any thoughts of self-harm.

Judgment: patient’s judgment appears to be intact. She is able to provide a clear explanation of her current situation and the reasons for her visit.

Overall functioning: patient reports struggling with daily tasks such as getting out of bed and maintaining personal hygiene. She reports difficulty with concentration and decision making. Comprehensive Evaluation Of Depression Assignment

Differential Diagnoses:

Major depressive disorder: the patient’s symptoms of low mood, loss of interest in activities, and changes in appetite are consistent with major depression. To be diagnosed with major depressive disorder, the patient must have experienced at least five of the following symptoms for at least two weeks: depressed mood, loss of interest in activities, changes in appetite, insomnia or hypersomnia, psychomotor agitation or retardation, fatigue, feelings of worthlessness or excessive guilt, difficulty thinking or concentrating, and thoughts of death or suicide (American Psychiatric Association, 2013).

Bipolar disorder: the patient’s symptoms may also be consistent with bipolar disorder, which is characterized by periods of low mood and loss of interest in activities, as well as periods of high mood and increased activity levels. To be diagnosed with bipolar disorder, the patient must have experienced at least one episode of mania or hypomania, and may also have experienced periods of major depression (Bobo, 2017)Comprehensive Evaluation Of Depression Assignment. The DSM-5 diagnostic criteria for bipolar disorder include: elevated mood, increased energy or activity, inflated self-esteem, decreased need for sleep, more talkative than usual, flight of ideas, distractibility, increased goal-directed activity, and excessive involvement in pleasurable activities.

Substance Use Disorder: the patient’s symptoms may be caused by the use of alcohol or other substances, which can impair mood and lead to changes in appetite and energy levels. To be diagnosed with a substance use disorder, the patient must have experienced at least two of the following symptoms within the same 12-month period: continued substance use despite negative consequences, failure to fulfill major role obligations, recurrent use in hazardous situations, persistent social or interpersonal problems, tolerance, withdrawal, and substance use to relieve withdrawal symptoms. Further evaluation and testing will be needed to determine which, if any, of these conditions is causing the patient’s symptoms.

Reflections: In reflecting on the interview, my preceptor and myself used a variety of therapeutic communication techniques to establish a strong therapeutic relationship with the patient and facilitate a productive and beneficial conversation. We began by introducing ourselves and explaining the purpose of the interview, and we used open-ended questions to encourage the patient to share her experiences and feelings. For example, we asked the patient about her symptoms, her daily routine, and any challenges or stressors she may be facing. We also used reflective listening to demonstrate our understanding and empathy, and to encourage the patient to continue sharing her thoughts and feelings. For example, when the patient mentioned feeling hopeless and struggling with daily tasks, we reflected back her words and affirmed her feelings. We also provided the patient with education and information about her condition, including the potential causes and treatments for depression. We encouraged the patient to ask questions and express any concerns she may have, and we provided her with resources and support to help her manage her symptoms. Comprehensive Evaluation Of Depression Assignment

Case Formulation and Treatment Plan:

JK is a 42 year old Caucasian female with symptoms of depression, including depressed mood, loss of interest in activities, changes in appetite, difficulty with daily tasks, and feelings of hopelessness. Her medical history includes a family history of depression, and she reported experiencing a significant life stressor in the form of losing her job. She also engages in occasional alcohol use. The patient’s symptoms are likely caused by a combination of genetic predisposition and environmental stressors. The patient’s family history of depression suggests a genetic vulnerability, and the loss of her job may have triggered the onset of her symptoms. Additionally, the patient’s occasional alcohol use may be exacerbating her symptoms. The patient’s symptoms are likely being maintained by a combination of negative thinking patterns and social isolation. She reports having negative thoughts about herself and her future, which may be contributing to her low mood and feelings of hopelessness. She also lives alone and does not have a strong social support network, which may be contributing to her feelings of isolation.

Treatment Plan

Prescribe fluoxetine 20 mg orally once daily, with a gradual increase to 40 mg orally once daily if needed. Fluoxetine is a selective serotonin reuptake inhibitor (SSRI) that is commonly used to treat depression (Davey et al., 2019)Comprehensive Evaluation Of Depression Assignment. The starting dose of 20 mg orally once daily is generally well-tolerated, and may be increased to 40 mg orally once daily if needed to improve the patient’s symptoms.

Refer the patient for cognitive-behavioral therapy (CBT) with a trained mental health provider. CBT is a form of therapy that focuses on identifying and changing negative thinking patterns and behaviors that contribute to the patient’s symptoms (Gautam et al., 2020). The patient will meet with a therapist on a regular basis to work on identifying and challenging her negative thoughts and developing more effective coping strategies.

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Encourage the patient to engage in regular exercise and physical activity. Exercise has been shown to improve mood and reduce symptoms of depression (Miller et al., 2019). The patient should aim to engage in at least 30 minutes of moderate-intensity physical activity, such as walking or cycling, on most days of the week.
Encourage the patient to engage in social activities and develop a strong social support network. Social support can be an important factor in improving mood and reducing symptoms of depression (Miller et al., 2019). The patient should be encouraged to participate in activities that she enjoys, such as joining a club or taking a class, and to make an effort to connect with friends and family members on a regular basis.
Schedule regular follow-up appointments to monitor the patient’s progress and make any necessary adjustments to the treatment plan. The patient should be seen by her healthcare provider at least every two to four weeks to assess her response to the medication and therapy, and to make any necessary adjustments to the treatment plan. The patient should also be encouraged to contact the healthcare provider if she experiences any worsening of her symptoms or any adverse effects from the medication. Comprehensive Evaluation Of Depression Assignment

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

Bobo, W. V. (2017, October). The diagnosis and management of bipolar I and II disorders: clinical practice update. In Mayo Clinic Proceedings (Vol. 92, No. 10, pp. 1532-1551). Elsevier. https://www.mayoclinicproceedings.org/article/S0025-6196(17)30544-X/pdf

Davey, C. G., Chanen, A. M., Hetrick, S. E., Cotton, S. M., Ratheesh, A., Amminger, G. P., … & Berk, M. (2019). The addition of fluoxetine to cognitive behavioural therapy for youth depression (YoDA-C): a randomised, double-blind, placebo-controlled, multicentre clinical trial. The Lancet Psychiatry, 6(9), 735-744. https://doi.org/10.1016/S2215-0366(19)30215-9

Gautam, M., Tripathi, A., Deshmukh, D., & Gaur, M. (2020). Cognitive behavioral therapy for depression. Indian journal of psychiatry, 62(Suppl 2), S223. https://doi.org/10.4103/psychiatry.IndianJPsychiatry_772_19

Miller, K. J., Mesagno, C., McLaren, S., Grace, F., Yates, M., & Gomez, R. (2019). Exercise, mood, self-efficacy, and social support as predictors of depressive symptoms in older adults: Direct and interaction effects. Frontiers in psychology, 10, 2145. https://doi.org/10.3389/fpsyg.2019.02145 Comprehensive Evaluation Of Depression Assignment

Subjective:

CC (chief complaint): “I have been having terrible nightmares. I feel so depressed. I am extremely anxious and I need help.”

HPI: A 35 year old female, RK, reports symptoms of nightmares, extreme depression, and anxiety. States that her symptoms started six months ago. She recounts that she was attacked while buying gas from a gas station at night. States that her assailant beat her and drug her behind the gas station, and robbed her of her money. States that she was left for dead, and was found three days later. She states that during that time, she went in and out of consciousness multiple times and she was so weak that she could not call out for help. States that she spent 4 weeks in the hospital for physical injuries, which included a broken right upper arm and multiple bruises to her face and legs. States that post hospitalization, she was given a referral to a psychiatrist but never followed up because she didn’t believe it was necessary. She also stated financial reasons for not following up. She describes her symptoms as occuring everyday over the last six months. States that her nightmares terrorize her every time she needs to sleep, states that she has lost her appetite, states that sheno longer enjoys activities that she previously enjoyed, and she does not go out with her friends any more. States that her family moved to a different location in the state because of this. States that her new address was a block away from another gas station. States that this has not helped her. She describes other associated symptoms like palpitations, shortness of breath, profuse sweating whenever she sees a gas station or when she is about to sleep. States that she previously enjoyed reading, but she no longer enjoys it. States that she has lost ten pounds within the last six months due to her poor appetite. States that the scars on her arms and face remind her of her experience and prevent her from being able to put it behind her. She denies psychiatric symptoms of auditory, visual, or tactile hallucinations. She denies suicidal ideations. She denies compulsive behaviors, delusions, paranoia, impulsivity, and eating disorder. She denies psychosis and any cognitive decline. (include psychiatric ROS rule out)

Past Psychiatric History: No past psychiatric illness. She was admitted to the hospital for four weeks after being physically assaulted about six months ago. She admits to feeling depressed, having nightmares, and experiencing anxiety. She denies suicidal ideations, illicit drug use. She has not seen a psychiatrist or gone to counseling for her symptoms for follow up. Comprehensive Evaluation Of Depression Assignment

General Statement: RK is a 28 year old who has been experiencing nightmares because of anxiety for the past six months.
Caregivers (if applicable): N/A
Hospitalizations: She was admitted to the hospital for physical injuries as a result of being physically assaulted. She was admitted to the hospital for three weeks for her injuries. States that prior to that, she had never been admitted to the hospital.
Medication trials: She has not been on any pharmacological agent.
Psychotherapy or Previous Psychiatric Diagnosis: Patient does not have any psychiatric diagnosis. She denies any medical diagnosis. She does admit to dramatic experience after she was physically assaulted. She admits to being referred to a psychiatrist, but she never followed up. She states that financial strains and fear of going out prevented her from following up.

Substance Current Use and History:

Family Psychiatric/Substance Use History: Patient denies family psychiatric history or substance use.

Psychosocial History: Patient was born and raised in Florida by her parents. Both parents are alive. She currently lives at home with her parents. She is an only child. She is currently divorced. Her first marriage was at the age of 20, states that she divorced after six months. Her second marriage was at the age of 24, states that the marriage lasted for two years before the divorce. She does not have any children. She graduated from college with a degree in accounting. She is currently unemployed. States that she lost her job after her physical assault because she could no longer perform her job efficiently. States that she once enjoyed reading and swimming, however, she has stopped both. Comprehensive Evaluation Of Depression Assignment

Medical History: She denies any medical history. Physical assault six months ago. She denies any other medical history. She denies any history of diabetes, hypertension, rheumatoid arthritis, etc.

Current Medications: None
Allergies: No known food or drug allergies.
Reproductive Hx: Patient states that she had her first onset at the age of 13 and she has regular menstrual frequency. She denies any complications.

Objective:

Diagnostic results: Mental health disorders present as vague manifestations and can be difficult to diagnose and treat. For this reason, different kinds of diagnostic tests need to be utilized to ensure accurate diagnosis and optimal interventions. Diagnostic testing is extremely important when it comes to determining a diagnosis for a particular patient. For instance, evaluating a patient’s bloodwork can be essential to give insight into the patient’s somatic condition. When the presence or absence of a somatic condition is determined, it becomes easier for mental health disorders to be detected (Memic-Serdarevic, 2020). A CMP test can assist in obtaining information on a patient’s liver functions. These tests also provide data on electrolytes, glucose levels, and kidney function. In addition, other tests lead to determination of organ functions and metabolism of the patient. Urinalysis has been proven to be able to accurately distinguish between depression and infections (Chen et al., 2018)Comprehensive Evaluation Of Depression Assignment.

Assessment:

Mental Status Examination: 28 year old Caucasian female who looks stated age. She is cooperative, groomed, and appropriately dressed. Her mood is clear. Her speech is clear, low in volume and tone. She shows signs of anxiety and low mood during examination. She sometimes sounded agitated in her communication. Her thought process is appropriate. She does not exhibit any evidence of flight of ideas or looseness of association. Her mood is depressed. Her affect is appropriate. She does not exhibit any abnormal motor activity. She denies visual and auditory hallucinations. She does not show any evidence of delusions. She denies current suicidal or homicidal ideations. She is alert and oriented. Her concentration is normal. Her memory is intact. She does not show any deficit in her insight or judgement.

Differential Diagnoses:

PTSD: Posttraumatic stress disorder refers to symptoms related to a major traumatic life event. The event can be one or several incidents. The diagnosis is common when a patient is consistently exposed to the traumatic event over long periods of time (Bisson et al., 2015). The DSM-5 criteria for PTSD classifies these traumatic experiences as exposure to serious injury, mental threats, actual death, and sexual violence. Manifestations of PTSD include profound inability to enjoy certain activities and being constantly overwhelmed with thoughts about the traumatic event. The patient, RK, expressed severe nightmares, terror dreams, and constant rumination about the event. Being physically assualted and left for dead for over three days caused her to experience extreme fear, poor concentration, insomnia, and inability to function on the job. The DSM-5 criteria for PTSD include direct or indirect exposure to traumatic events with subsequent symptoms in four different categories. These categories include negative change in thoughts and mood, intrusive thoughts, avoidance, and changes in arousal and reactivity. (Tull, 2022)Comprehensive Evaluation Of Depression Assignment.

GAD: People diagnosed with general anxiety disorder typically exhibit fear, worry, and the feeling of being overwhelmed (Munir & Takov, 2022). RK reports fear and anxious feelings when she sees gas stations, and is overwhelmed by night terrors and nightmares about her traumatic experience. Difficulty sleeping and/or sleep disturbance are also symptoms of anxiety disorder, and RK’s nightmares pertaining to her experience contribute to that.

MDD: RK reports having poor appetite, changes in sleep pattern, inability to enjoy her hobbies, and depressed mood for the last six months. Her social functioning and occupational functioning were both affected because of the traumatic event. The DSM-5 critieria for major depressive illness include five or more of the following; diminished ability to focus, recurring thoughts of death or suicidal ideation, loss of interest, weight loss, insomia, depressed mood, agitation, fatigue, and feelings of worthlessness (APA, 2013)Comprehensive Evaluation Of Depression Assignment. RK’s symptoms cannot be attributed to the effect of substance abuse and meet the criteria as outlined.

Reflections: In reflecting on the interview, my preceptor and myself used therapuetic communication in performing this interview. The interview was well done in order to determine the exact psychiatric illness and the appropriate treatment intervention for the patient. I learned that communication techniques are always significant in the interviewing process. Techniques such as open ended questions, active listening, demonstrating empathy all paved the way to ilicit appropriate responses from the patient. The provider or interviewer should not try to impose their opinion, but allow the patient to express themselves. This patient did not recognize the seriousness of the mental health impact from her traumatic event. She waited for a while before realizing that there was a continuous decline and that she needed to follow up with a psychiatrist. For this reason, she needs constant reassurance and requires close monitoring. Since she lives with her parents and has a good relationship with them, it would be beneficial to attempt to include her family in therapy sessions, if she is agreeable. Her treatment should include both pharmacological and non pharmacological interventions. The principle of benevolence and autonomy should be observed while treating this patient. Comprehensive Evaluation Of Depression Assignment

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Case Formulation and Treatment Plan:

RK is a 28 year old Caucasion female who presents with a six month history of traumatic life events leading her to feel depressed, lose interest in activities, weight loss, poor appetite, insomnia, fear, palpitations, nightmares, and the inability to socialize or hold a job. She’s unable to go out most of the time to socialize with friends. For the past six months, she did not seek psychiatric help for fear of getting out of her house. Her mental status assessment shows speech is clear, normal volume, although she exhibits depressed mood, and some agitation. Her thought process, insightand judgement, were all assessed as intact. She has no prior psychiatric diagnosis and was not on anypsychiatric medications. Her family history was also negative for any mental health disorders or any ilicit drug use. Clinical guidelines for managing PTSD should include the use of pharmacotherapy and psychotherapy. Medications that have been approved for treatment of PTSD are Paroxetine and Sertraline. Family psychotherapy will be essential if patient is agreeable to ensure improvement in her condition. When RK consents, community organizations that can offer financial and social assistance should be included in her treatment plan.

Treatment Plan

Pharmacotherapy with antidepressants
Individual psychotherapy*
Cognitive behavioral therapy
Family psychotherapy*
Referral to a psychiatrist
Referral to a physician
Referral to Catholic charities Comprehensive Evaluation Of Depression Assignment