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Week 4: Comprehensive Psychiatric Evaluation Note and Patient Case Presentation

Nneamaka Anara

College of Nursing-PMHNP, Walden University

PRAC 6675: PMHNP Care Across the Lifespan II

Dr. Fletcher

06/21/2023

Objectives

· Elicit DSM-V crieteria for the diagnosis of mood disorders and unspecified mood disorders

· Identify subtle/uncommon signs and symptoms of mood disorders

· Access and implement best therapeutic measures in the treatment of atypical presentation of depression

· Utilize non-pharmacological measures in the treatment of depression

Subjective:

CC (chief complaint): “I need someone to talk to”

HPI: History of Presenting Complaints: N.K is a 68 year-old widowed, retired, African American female with no past history of psychiatric diagnosis. She presents to the clinic with complaints of recent sad mood due to the loss of her husband 6 years ago. Patient states that she went through domestic and sexual abuse in the hands of her first husband for 14 years. She later remarried but lost her second husband 6 years ago. She states that her last husband died in her hands while performing CPR. Patient states she always occupies her time with her business and is very involved in the life of her children, grand children, and great-grand children which also happens to be her system of support. She currently lives alone and enjoys cooking and gardening which also has contributed to her healthy lifestyle. She endorsed good appetite and states she eats healthy meals and snacks. She denies insomnia and states she sleeps about 7/8 hours per night on the average. She denies any active suicidal or homicidal ideations. She denies any visual or auditory hallucinations. 

Substance Current Use: Denies substance use

Medical History:

· Current Medications: Simvastatin 10 mg oral tablet, hydrochlorothiazide 25 mg oral tablet

· Allergies: No known drug, food or environmental allergies

· Reproductive Hx: Menopause at age 50. No sexuaI concerns

ROS:

· HEENT: No visual loss, blurred vision, double vision. Ears: Denies ear popping or crackling. Denies hearin loss. Nose/throat: Denies nose bleeds or sinus pain, No sneezing or nasal congestion. No complaints of throat pain.

· SKIN: No rash or skin breakdown

· CARDIOVASCULAR: No chest pain, no palpitations

· RESPIRATORY: No difficulty breathing, cough or sputum

· GASTROINTESTINAL: No abdominal pain, no anorexia, nausea, diarrhea or vomiting.

· GENITOURINARY: No urinary urgency, hesitancy or burning sensation

· NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia. No change in bowels.

· MUSCULOSKELETAL: No back pain or muscle ache. No joint stiffness

· HEMATOLOGIC: No bleeding, bruising, or anemia

· LYMPHATICS: No enlarged nodes. No history of spleenectomy

· ENDOCRINOLOGIC: No reports of cold or heat intolerance. No polyuria or polydipsia

Objective:

Diagnostic results: DSM-5, Generalised Anxiety Disorder (GAD-7), PCL checklist, Patient health questionnaire PHQ-9). TSH test because the symptoms of hypothyroidism mimicks the symptoms of depression, which came back normal. The DSM-5 states that all depressive mood disorders share the same trait of having a sad, empty, or irritable mood along with other changes that have a significant impact on the person's ability to function, such as somatic and cognitive changes in major depressive disorder and persistent depressive disorder. Differences between them relate to questions of duration, timing, or alleged reason (DSM-5, 2022)

Assessment:

Mental Status Examination: N.K is a 68-year-old African American female who look sher staged age. She appears well groomed and nourished. She answers questions appropriately with few nods and smiles. She is cooperative with the examiner and makes appropriate eye contact. Her speech is clear and coherent, normal in tone and volume. There is no evidence of losseness of association or flight of ideas. Normal affect appropriate to mood. There is no abnormal motor activity. There is no evidence of delusional thinking. Patient denies any visual or auditory hallucinations. She denies any suicidal or homicidal ideations. She is Alert and oriented to person, place, time and situation.

Diagnostic Impression:

Unspecified mood [affective] disorder - F39, Primary diagnosis: When a presentation does not fit the criteria for a certain mood disorder and it is difficult to decide between an unspecified depressive disorder and unspecified anxiety disorder, the term "unspecified mood disorder" is used (Taş, 2019). Unspecified mood disorder is determined to be an accurate DSM-V diagnosis when there is insufficient or conflicting information about the patient and the symptoms of a mood disorder are insufficient to diagnose a specific mood disorder. N.K, appears to currently meet the diagnosis of unspecified mood disorder because her PHQ-9 score was 3, and other diagnostic tests such as TSH levels were normal. More so, she also states her sad mood started only recently.

Major Depressive Disorder – F33.1: This is a mental illness that can either be significant depression or clinical depression. More than 200 symptom combinations can be used to make the diagnosis of a major depressive episode (MDE) according to the Diagnostic and Statistical Manual of Mental Disorders' (DSM) current criteria, highlighting the disorder's notable clinical variability (Kennedy & Ceniti, 2018). Grief in response to a catastrophe like a family member's death, a job loss, or a serious sickness can also cause it. It may be clinical depression or serious depression if the condition continues after the stressful events have passed (Rakofsky & Rapaport, 2018). Additionally, there are other subtypes of depression, including postpartum depression, seasonal affective disorder, persistent depressive disorder, and psychotic depression. In this case, my patient N.K is dealing with the loss of her husband and loneliness as she came in with complaints of needing someone to talk to. She does not meet the criteria for the diagnosis of depressive disorders.

Bipolar Disorder – F31.32: Manic-depressive disorder, or mood fluctuations from depression to mania, is another name for this illness. The individual's sleep, behavior, judgment, and capacity for rational thought may all be impacted by the mood fluctuations. Bipolar disorder comes in a variety of forms, including bipolar I, II, and cyclothymic disorder (Vieta et al., 2019). Although this ailment can strike at any age, it is typically discovered in teenagers, and each person will experience it differently. My patient N.K does not meet the criteria for the diagnosis of bipolar disorder.

Attention Deficit Hyperactivity Disorder (ADHD) – F90.9: An impairment in levels of inattention, disorganization, and/or hyperactivity-impulsivity characterizes ADHD, a neurodevelopmental condition (DSM-5, 2022). Disorganization and failure to pay attention include inattentiveness, lack of attention at levels that are inconsistent with age or developmental stage. Frequent fidgeting, not being able to sit still, overactivity, and an inability to wait are all indicators of hyperactivity-impulsivity. These behaviors are excessive for the person's age or developmental stage. With the resulting impairments in social, academic, and occupational performance, ADHD frequently continues into adulthood. In female ADHD patients, anxiety and depression frequently coexist. However my patient N.K is not dealing with ADHD symtomps and does not meet the criteria for its diagnosis based on the DSM-5 criteria for ADHD.

Reflections:

Providing care for this patient was quite challenging because she does not fully meet the diagnosis for a specific mood disorder given the DSM-V criteria. I questioned why the patient should not atleast be started on Prozac. However, I enjoyed the growth behind it as I realized that not all patients will need to be started on medications given their symptoms in order to feel better. While working this patient I educated on the importance of staying up-to-date on her vaccines and maintaining yearly visits with her OBGYN and regular PCP visits to manage her blood pressure and cholesterol. Education was also provided on the importance of maintaining a healthy diet and exercise such as going on daily walks because studies have shown that these practices promote mental and physical well being.

In addition, I had the opportunity of meeting N.K again during one of her weekly therapy visits. She expressed how grateful she was to her therapist and the progress she is making in terms of dealing with the sadness of not having a male partner in her life. She also told me how coming to her weekly therapy sessions has improved her outlook on life in general.

Case Formulation and Treatment Plan: 

Therapy Only

- Start therapy ASAP

- Instructed to call office if non-emergent concerns, but to seek immediate emergent care if there are abnormal changes in behavior, thoughts of suicide or self-harm. 

- Medical Records/Labs/Diagnostic Tests Reviewed

- Risks, benefits, alternatives and possible side effects discussed with patient. Consent obtained.

According to Saunders et al. (2021), a quarter of older adults (over 65s) have a common mental disorder (CMD) such as depression or anxiety disorder and psychotherapies such as cognitive behavioral therapy (CBT) are proven to be effective (Saunders et al. 2021). There is a patient preference for psychological therapies over antidepressant medications, and there are fewer side effects with psychotherapies. Given N.K’s age and chief complaints, she would benefit so much from psychotherapy.

Questions:

1. Do you agree with the patient’s diagnosis? Why or why not

2. Do you agree with psychotherapy as the treatment plan for this patient?

3. What would you have done differently?

PRECEPTOR VERFICIATION:

I confirm the patient used for this assignment is a patient that was seen and managed by the student at their Meditrek approved clinical site during this quarter course of learning.

Preceptor signature: ________________________________________________________

Date: ________________________

References

Depressive disorders. (2022). Diagnostic and Statistical Manual of Mental Disorders. https://doi.org/10.1176/appi.books.9780890425787.x04_depressive_disorders

Kennedy, S. H., & Ceniti, A. K. (2018). Unpacking Major Depressive Disorder: From Classification to Treatment Selection.  The Canadian Journal of Psychiatry,  63(5), 308–313.  https://doi.org/10.1177/0706743717748883

Neurodevelopmental disorders. (2022). Diagnostic and Statistical Manual of Mental Disorders. https://doi.org/10.1176/appi.books.9780890425787.x01_neurodevelopmental_disorders

Rakofsky, & Rapaport, M. (2018). Mood disorders. CONTINUUM: Lieflong Learning in Neurology, 24(3), 804-827

Saunders, R., Buckman, J. E., Stott, J., Leibowitz, J., Aguirre, E., John, A., Lewis, G., Cape, J., & Pilling, S. (2021). Older adults respond better to psychological therapy than working-age adults: evidence from a large sample of mental health service attendees. Journal of Affective Disorders, 294, 85–93. https://doi.org/10.1016/j.jad.2021.06.084

Taş, H. İ. (2019). Evaluation of the diagnostic continuity of unspecified mood disorder.  Düşünen Adam.  https://doi.org/10.14744/dajpns.2019.00015

Vieta, E., Berk, M., Schulze, T. G., Carvalho, A. F., Suppes, T., Calabrese, J. R., & Grande, I. (2018). Bipolar disorders. Nature reviews Disease primers, 4(1), 1-16.