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Subjective:

CC (chief complaint): “I always feel completely miserable since my brother passed away."

HPI: the patient's name initials are B.B, a twenty-two-year-old Canadian female who presents for psychiatric evaluation for a mood disorder. The patient has been having this issue since when her brother died that is three months ago. B.B shows symptoms of a mood disorder, and her disorder has been attributed to the death of an essential person in her life. Her current symptoms include; feeling sad, anxious mood and empty. The patient states that her appetite has decreased, she has also lost weight, and she says that the weight loss has occurred during that period of her grief. She also has issues of concentration difficulty, which are related to her depressive symptoms. She also stated that she has been having sleeping difficulties. The patient also says that she does not enjoy the things that made her happy before. Her severity is estimated to be moderate since she has a risk of morbidity without treatment, as well as her description of interference in functioning.

Past Psychiatric History:

· General Statement: the patient stated that she has never been treated for depression or related disorders.

· Caregivers (if applicable):

· Hospitalizations: B.B stated that she has never been psychiatrically hospitalized.

· Medication trials: the patient denies previous psychotropic medications that she has tried.

· Psychotherapy or Previous Psychiatric Diagnosis: the patient denies any previous psychiatric diagnosis

Substance Current Use and History: B.B denies any current or history of substance use. There is no history of B.B ever having withdrawal from any substance.

Family Psychiatric/Substance Use History: no mention of any substance use, specifically the first-degree relatives. In her family, her father is reported to have anxiety; her sister also is thought to have depression. The family psychiatric history is or else negative. Although, there is no other history of psychiatric disorders, suicidal behavior, no history of substance abuse in the family, or any psychiatric treatment.

Psychosocial History: B.B is a twenty-two-year-old female who is a Canadian, and she is a Christian. She is not married. The patient was raised by both of her parents, her mother and her father. She has one sister and a brother who died, and she is the firstborn in her family. She is currently living with her parents as she is still in school and her sister who is now left is still in school. The patient is studying in a specific university doing education course. The patient still works in her free time thus she is employed; she has no history or childhood history of trauma.

Medical History:

· Current Medications: currently, the patient does not take any medication

· Allergies: there are no known allergies.

· Reproductive Hx: the patient is not pregnant, and she has no ny kids as she is still in school. She is using a contraceptive which she admitted is a contraceptive implant. She states that she uses vaginal intercourse, and there are no sexual issues.

ROS:

· GENERAL: the patient states that she has been feeling sad, anxious since her brother died three months ago. She says that she only wants to be okay. The patient states that she has been feeling miserable since her brother passed away. The patient states that she has weight loss and that her appetite has decreased. She denies any fever, weakness, or fatigue.

· HEENT: the patient denied headache; there is no complaint of vision loss, eye discharge, redness, or tearing. There is no mention of the loss of hearing no ear drainage; she states that she does not have nasal congestion and no bleeding of gums.

· SKIN: she denies any changes in the skin and states that her skin has remained normal.

· CARDIOVASCULAR: there is no mention of chest pains.

· RESPIRATORY: she states that she does not have shortness of breath or cough.

· GASTROINTESTINAL: there is no record of diarrhea, no record of nausea or vomiting. However, the patient states that her appetite has decreased.

· GENITOURINARY: B.B states that she has not experienced discomfort or irritation; she also says that she has no virginal discharge or any pain when urinating.

· NEUROLOGICAL: The patient states that she has not experienced severe headaches, no dizziness, or memory loss.

· MUSCULOSKELETAL: she states that she has not experienced any pain in the bones, joints, and muscles. She says that she has no constraint to a range of motion or joint swelling.

· HEMATOLOGIC: the patient states that she has not experienced bruising or bleeding and denies anemia.

· LYMPHATICS: the patient says that she has no history of splenectomy and denis enlarged nodes.

· ENDOCRINOLOGIC: the patient states that she has not experienced sweating, heat intolerance, or cold.

Objective:

Physical exam: the personal hygiene of the patient was good, she was appropriately dressed, and her engagement was good as she expressed herself. The patient did not look directly at the caregiver, and she seemed distressed, and one could see that she has a lot of thoughts in her mind. She could be distracted by something small. Also, according to her age, her behavior was kind of appropriate.

Diagnostic results:

Assessment:

Mental Status Examination: The patient was sad, and she could cry in the session when she mentions her late brother. The length of speech of the patient was average, and she communicated usually. She had a weight issue which she stated that she had lost weight since her brother's death. Her speech tone was normal. She had no hallucinations, she thought content was average, and she felt sad, and she also felt miserable. She was intact in time. The patient looked like her declared age, and she did not look to be well; she was mildly distressed, oriented, and alert.

Differential Diagnoses:

Primary diagnostic- the primary diagnostic for the patient is adjustment disorder with depressed mood. ICD10- F43.23. According to DSM 5, this disorder is defined as behavioral or emotional symptoms in response to a stressor or identified stressors. This disorder can be with depressed mood (Mayoclinic., 2017). The symptoms include feeling sad, which is one of the symptoms depicted in my patient. Also, the patient is tearful and hopeless, and the patient does not experience pleasure in the things they used to enjoy. In this case, the patient was crying in the session and stated that the things she used to enjoy before she does not enjoy them anymore, which is also a symptom of this disorder. Another symptom of this disorder defined by DSM 5 is difficulty concentrating, which is also a symptom that my patient has shown. The patient stated that she has been having difficulty concentrating. In brief, I can say that all the symptoms that the patient depicted aligned with this disorder.

Differential diagnosis- persistent depressive disorder ICD 10- F34.1

This disorder is also known as dysthymia, which is a milder, but long-lasting form of depression. The symptoms of this disorder that our patient depicts are loss of interest in daily activities (George F. Parker, 2014). My patient stated that she was no longer interested in things that she used to enjoy before, affecting her functioning. Also, another symptom of this disorder is feeling sad, empty, or feeling down. The patient has been feeling sad, empty, and down, which states that she might be having this disorder. My patient also said that she has trouble concentrating which is also another symptom of this disorder. The symptoms of the disorder that the patient does not show are lack of energy, low self-esteem, excessive anger.

Another disorder that this patient might have is bipolar disorder ICD 10 F31. This disorder can be brought about by a death of a loved one which is our case with B.B. Some of the symptoms of this disorder that B.B shows are having sleeping issues. This is one of the symptoms of this disorder that my patient depicts. Also, another sign is easily distracted, which is also another symptom that B.B shows. Although most of the symptoms of this disorder, our patient does not have impaired judgment, feeling able to do anything, engaging in risky behavior, etc.

Reflections: this situation is faced by many people, especially those who lose the people they value most in their lives. Most of the symptoms that the patient depicts relate to adjustment disorder with depressive mood. One thing that I could do differently if I could conduct the session again is involving her family.

Treatment- for this disorder, the patient needs psychotherapy which is the primary treatment for this disorder (Lindsey Toler, 2021). The patient can either be provided with this treatment as a family or individually. I will advice my patient to be doing physical exercises which will help her in her condition. I will also educate her on how to change some of her lifestyle including eating a nutricious diet and getting enough sleep.

References