Assignment: Assessing, Diagnosing, and Treating Adults With Mood Disorders

1

Comprehensive Psychiatric Evaluation

Student Name

University

Course

Professor Name

Date

Comprehensive Psychiatric Evaluation

CC (chief complaint): Wound up. Lost temper because the kids get on my nerves. The kids play the television too loud. For instance, Shawn spilled sugar all over the counter last night when my husband was out. I think I should not be here.

HPI: L.C., a 49-year-old female, presents for psychiatric evaluation for mood disorder. Currently, she is not prescribed psychotropic treatments. Her therapist referred her for medication evaluation and treatment. The patient seems like she is depressed. She presents all the symptoms of depression including loss of sleep, worry, memory loss, the feelings of exhaustion and irritability. The symptoms have made working difficult for her and even caused her suicidal thoughts. The patient has been having these symptoms for the past three months. Apparently, the depression was caused by a missed promotion.

Past Psychiatric History:

General Statement: This makes the patient’s first visit due to depression.

Hospitalizations: The patient has never been hospitalized for any psychotropic medication. The patient has never had detox/residential treatment. No past suicidal or homicidal behaviors.

Medication trials: the patient tried her husbands sleeping pills but proved to be not effective.

Psychotherapy or Previous Psychiatric Diagnosis: the patient does not know the type of mental illness she is suffering from.

Substance Use History: Currently, the patient takes alcohol. She takes three or four stiffs a day.

Family Psychiatric/Substance Use History: The patient’s sister has depression. The mother has a history of being a “functioning alcoholic”.

Social History: The patient was born and raised in Indianapolis, IN by her mother. She has two sisters. The father died while she was 2 years old. Currently, she lives in Indianapolis, IN with her husband and three children, three boys who are all teenagers. She has an MBA. She is currently working full-time as a logistics buyer in a medical facility. She denies any history of trauma.

Medical History: She was recently informed by her PCP that she has a “fatty liver”.

Current Medications: She is not using any medications currently.

Allergies: She reported of having latex allergy.

Reproductive Hx: She engages in vaginal sexual intercourse.

ROS:

GENERAL: Experiencing fatigue, weight loss, fever, chills, weakness.

HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.

SKIN: Rash and itching.

CARDIOVASCULAR: Chest pain, chest pressure, chest discomfort, palpitations and edema.

RESPIRATORY: Shortness of breath, cough, sputum, and nightly symptoms.

GASTROINTESTINAL: Anorexia, nausea, vomiting, diarrhea, abdominal pain or blood.

GENITOURINARY: Burning on urination, urgency, hesitancy, odor, odd color

NEUROLOGICAL: Headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. Change in bowel and bladder control.

MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness.

HEMATOLOGIC: Anemia, bleeding, and bruising.

LYMPHATICS: No enlarged nodes. No history of splenectomy.

ENDOCRINOLOGIC: Sweating, cold, and heat intolerance. Polyuria and polydipsia.

Diagnostic results:

A ssessment

Mental Status Examination: Mrs. Louise Carson, a 49-year-old female, got evaluated. She was about 6’ tall, put on a floral print dress, and seemed exactly like her stated age. She had groomed adequately and cooperated well with the examination. She claimed of having a “desperate” mood since she had recently missed a promotion. Mrs. Carson’s affect was overwhelmed by intermittent anxiety, which was generally linked with having difficulty responding to the examiner’s questions. Mrs. Carson’s speech was soft, slow, and halting. She denies any auditory or visual hallucinations. She reports of having suicidal and homicidal ideation. She is restless; repeatedly asking as to whether she had an acceptable appearance. She was familiar about the place and person, but wrote the date as December 2, 1973 (today is September 17, 2021). Her judgement, insight and reliability were greatly impaired.

Differential Diagnoses:

1. Clinical Depression

2. Anxiety Disorder

3. Bipolar Disorder

Primary Diagnosis

Clinical Depression

It was the primary diagnosis for Mrs. Carson. Depression, also known as clinical depression or major depressive disorder, refers to a common and dire mood disorder. Patients of depression experience continuous feelings of hopelessness and sadness and suddenly lose interest in events they once seemed to enjoy (Pitsillou et al., 2020). Besides causing emotional problems, depression can also bring about physical symptoms like digestive issues and chronic pain. For one to be diagnosed as having depression the symptoms must have been present for at least two weeks.

The patient had experienced these symptoms for about three months – a proof that indeed she was suffering from depression. Moreover, the sister to the patient was diagnosed of having depression and hence, the condition can be genetic. Furthermore, as per DSM-5, the patient had experienced more than five of the symptoms necessary to declare a depression diagnosis and one of the symptoms was a depressed mood. The symptoms include: depressed mood, diminished interest in about all activities, great weight loss, fatigue, feelings of worthlessness, and recurrent suicidal thoughts.

Secondary Diagnosis

Anxiety Disorder

Anxiety patients experience symptoms such as excessive worry, overthinking as well as envisioning worse-case scenario, irritability, restlessness, muscle tension, trouble concentrating, fatigue, and sleep disturbances (Bandelow et al., 2017). As such, Mr. Carson’s symptoms also lie among the symptoms of anxiety. However, anxiety turned out to be a secondary diagnosis since for one to be diagnosed of having it they must have experienced the symptoms for the past six months. Contrarily, the patient has had the symptoms for merely three months. Furthermore, the DSM-5 diagnosis confirmed the patient to be suffering from depression.

Bipolar Disorder

Bipolar disorder, formerly referred to as manic depression, refers to a mental health illness which results in significant mood swings which includes emotional highs (mania) and lows (depression). The mood swings may have an adverse impact on sleep, judgement, energy, activity, as well as the ability to think rationally (Carvalho et al., 2020). Consequently, the fact that the patient had sleep problems, mood change and easily got fatigued is reason enough to associate the condition to bipolar disorder.

However, this could not have been the primary diagnosis since it is a lifelong condition; the patient had only had the symptoms for three months.

Reflection: As per my learning goals feedback, my weakest area and diagnosis that I ought to focus on is anemia. I can comfortably carry out a therapy for depression since for the patient to be seen they ought to have a referral from a counselling center, which Mrs. Carson had. However, in the case of iron deficiency anemia, it certainly is a case I ought to think over as far as the plan of treatment is concerned. In addition, I do recall storming out of the room having doubts that maybe the patient had another condition other than depression. The tests from the lab indicated that the patient had low ferritin and iron. Moreover, I was happy to about the plan and education for Mrs. Carson as we were able to deal with both anemia and depression. Reflecting on Mrs. Carson, I realized the significance of finding out all the possible causes and then pairing them. This exercise further taught me the significance of inter-professional collaboration especially with the counselling center.

References

Bandelow, B., Michaelis, S., & Wedekind, D. (2017). Treatment of anxiety disorders. Dialogues in clinical neuroscience, 19(2), 93.

Carvalho, A. F., Firth, J., & Vieta, E. (2020). Bipolar disorder. New England Journal of Medicine, 383(1), 58-66.

Pitsillou, E., Bresnehan, S. M., Kagarakis, E. A., Wijoyo, S. J., Liang, J., Hung, A., & Karagiannis, T. C. (2020). The cellular and molecular basis of major depressive disorder: towards a unified model for understanding clinical depression. Molecular biology reports, 47(1), 753-770.