PRAC 6635: Psychpathology Diagnostic Reason Practicum: Comprehensive Psychiatric Evaluation and Patient Case Presentation, Documentation

PRAC 6635:Psychpathology Diagnostic Reason Practicum: Comprehensive Psychiatric Evaluation and Patient Case Presentation, Documentation

A Sample Answer For the Assignment: PRAC 6635: Psychpathology Diagnostic Reason Practicum: Comprehensive Psychiatric Evaluation and Patient Case Presentation, Documentation

Title:  PRAC 6635: Psychpathology Diagnostic Reason Practicum: Comprehensive Psychiatric Evaluation and Patient Case Presentation, Documentation

CC (chief complaint): “I think too much. I cannot sleep.”

HPI: T.N. is a 29-year-old African American woman who came to the psychiatric clinic to be evaluated for depression symptoms. Due to lack of sleep, the patient reports decreased attention and productivity during the last 6 weeks. Most of the time, she professes to be melancholy, feeling empty and forlorn. The patient states that her relationship with her spouse has deteriorated since he accepted a job in a distant state, far away from their home. When her husband received the job offer, they were preparing to have a kid together. Since then, she has reported feelings of sadness and worthlessness, as well as a loss of interest in formerly enjoyable activities such as going out with her coworkers on weekends. Reports regular thoughts of suicide but denies any attempts. She has lost some weight over the past month due to a decrease in her appetite. She denies using medicine to treat her current psychological issues.

Past Psychiatric History:

  • General Statement: The client has been experiencing depressive symptoms since her husband transferred to a new location hundreds of kilometers away from their home.
  • Caregivers (if needed): She is presently living alone, with her husband visiting every two weeks.
  • Hospitalizations: No prior hospitalizations
  • Medication trials: She has not used any stimulant or prescription medication to address her mental disorder.
  • Previous Psychiatric Diagnosis or Psychotherapy: Confirms involvement in grief recovery support program, which she says was ineffective..

Substance Current Use and History: Confirms consuming one or two drinks before bedtime. Denies using marijuana, tobacco, or any other illicit drugs.

Family Psychiatric/Substance Use History: Refuses to acknowledge a family history of drug abuse or psychological illnesses.

Psychosocial History: The patient has just been married for four years. They shared a two-bedroomed house in a small town until her spouse left for Louisiana for a career opportunity two months ago. Before her partner received the job offer, they were struggling to conceive. She is employed at a downtown bookstore. She states that she works out and eats a nutritious diet every day. In her leisure time, she likes watching movies.

Medical History: There is no history of any medical issues.

  • Current Medications: None
  • Allergies: None
  • Reproductive Hx: LMP 21/12/2022. Menstruation is regular. Denies having reproductive illness in the past.

ROS:

  • GENERAL: Over the last two months, she has reported dropping weight. Confirms loss of appetite, sleep difficulties, and fatigue. Denies having diarrhea, constipation, a headache, chills, or fainting.
  • HEENT: Head: denies feeling dizzy, having headaches, or having seizures. Eye: denies experiencing any eye pain, redness, tears, irritation, or double vision. Ear: denies the presence of ear discharge, soreness, inflammation, or tinnitus. Nose:   no sneezing, nasal congestion, nose bleeding, sinusitis, or runny nose. Throat: denies dental problems, itchy throat, and swallowing difficulties.
  • SKIN: denies skin discoloration, itching, hives, or skin irritation.
  • CARDIOVASCULAR: No lower extremity edema, palpitations, breathlessness, arrhythmias, tightness of the chest, or pains.
  • RESPIRATORY: denies dyspnea, congestion, wheezing, cough, sputum, sinuses, or heavy breathing.
  • GI: denies nausea, fluid retention, stomach pains, anorexia, diarrhea, constipation, vomiting, or indigestion.
  • GENITOURINARY: no urinary incontinence, hematuria, hesitation, dysuria, or burning feeling during urinating.
  • NEUROLOGICAL: no paralysis, migraines, fainting, drowsiness, ataxia, or tingling in the extremities.
  • MUSCULOSKELETAL: no back discomfort, joint problems, or muscle soreness.
  • HEMATOLOGIC: no bruising, bleeding, or anemia.
  • LYMPHATICS: No lymphadenopathy or splenectomy.
  • ENDOCRINOLOGIC: no extreme sweating, polydipsia, or sensitivity to heat or cold

Physical exam: if applicable

Diagnostic results: To rule out physiological reasons for the patient’s symptoms, routine lab tests such as white blood cell count, TSH, vitamin B12, LFTS, Hepatitis C test, blood urea nitrogen, Hba1c, and urine and blood toxicology screening were arranged. To create differential diagnoses, the Patient Health Questionnaire (PHQ-9) and the Beck Depression Inventory (BDI) were employed (Leuchter et al., 2021).

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Assessment

Mental Status Examination: The patient enters the examining room dressed casually for her age. During the interview, she is nice and

PRAC 6635 Psychpathology Diagnostic Reason Practicum Comprehensive Psychiatric Evaluation and Patient Case Presentation, Documentation
PRAC 6635 Psychpathology Diagnostic Reason Practicum Comprehensive Psychiatric Evaluation and Patient Case Presentation, Documentation

cooperative. Her sense of time, place, and person is correct. She is gloomy, speaks softly, and avoids eye contact. Her judgment is appropriate for her level of education. Her understanding corresponds to her emotions. Her impact is flat. Her thought processes and contents are well developed. Both short- and long-term memory are intact. Suicidal ideation and insomnia have been documented. Denies experiencing hallucinations, psychosis, or suicidal ideation.

Differential Diagnoses:

  1. Major Depressive Disorder (MDD): The patient exhibits low mood, despair, worthlessness, reduced energy levels, loss of interest and pleasure, sleeping difficulties, and suicidal tendencies, all of which meet the DSM-V criteria for MDD (Gutiérrez-Rojas et al., 2020).
  2. Separation Anxiety Disorder: The patient’s mental health may have suffered as a result of her geographical separation from her partner, resulting in anxiety symptoms (Milrod et al., 2020).
  3. General anxiety disorder (GAD): The patient acknowledges fatigue, sleeping problems, and decreased attention and productivity at work, all of which point to GAD (Sapra et al., 2020).

 

Primary Diagnosis:

Major Depressive Disorder (MDD): The patient exhibits symptoms of depression such as low mood, helplessness, worthlessness, reductions in energy levels, loss of interest and pleasure, sleeping difficulties, and suicidal tendencies, which meet the DSM-V diagnostic criteria for MDD (Gutiérrez-Rojas et al., 2020).

Reflections: The adult female in the presented case study demonstrates signs of MDD. The data provided is adequate to establish this diagnosis, according to the DSM-V criteria. However, I would have advised the patient to try and convince her spouse to the therapy session, to help overcome their marital issues (Leuchter et al., 2021). While developing the care plan, a PMHNP must also respect the patient’s right to self-determination and autonomy by offering accessible treatment choices and recommending the most informed judgment based on evidence. The patient has the right to be informed about the advantages and adverse effects of the drugs administered to her. In achieving the Healthy People 2030 goal of creating a social and physical environment, and promoting health for all, it will be necessary to advise the patient to consider exercise programs within the community to promote both her physical and mental health (Abdoli et al., 2021).

 

PRAC 6635:Psychpathology Diagnostic Reason Practicum: Comprehensive Psychiatric Evaluation and Patient Case Presentation, Documentation References

Abdoli, N., Salari, N., Darvishi, N., Jafarpour, S., Solaymani, M., Mohammadi, M., & Shohaimi, S. (2021). The global prevalence of major depressive disorder (MDD) among the elderly: A systematic review and meta-analysis. Neuroscience & Biobehavioral Reviews. https://doi.org/10.1016/j.neubiorev.2021.10.041

Gutiérrez-Rojas, L., Porras-Segovia, A., Dunne, H., Andrade-González, N., & Cervilla, J. A. (2020). Prevalence and correlates of major depressive disorder: a systematic review. Brazilian Journal of Psychiatry, 42(6). https://doi.org/10.1590/1516-4446-2020-0650

Leuchter, A. F., Wilson, A. C., Vince-Cruz, N., & Corlier, J. (2021). Novel method for identification of individualized resonant frequencies for treatment of Major Depressive Disorder (MDD) using repetitive Transcranial Magnetic Stimulation (rTMS): A proof-of-concept study. Brain Stimulation, 14(5), 1373–1383. https://doi.org/10.1016/j.brs.2021.08.011

Milrod, B., Keefe, J. R., Choo, T., Arnon, S., Such, S., Lowell, A., Neria, Y., & Markowitz, J. C. (2020). Separation anxiety in PTSD: A pilot study of mechanisms in patients undergoing IPT. Depression and Anxiety. https://doi.org/10.1002/da.23003

Sapra, A., Bhandari, P., Sharma, S., Chanpura, T., & Lopp, L. (2020). Using generalized anxiety disorder-2 (GAD-2) and GAD-7 in a primary care setting. Cureus, 12(5). https://doi.org/10.7759/cureus.8224