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Mood Disorders sample Assignment: Assessing and Diagnosing Patients With Mood Disorders Subjective: CC (chief complaint): “I can't stop crying. All the time.” HPI: L.T is a 32-year-old black female who presents for psychiatric evaluation. Patient complains of a depressed mood almost every day since the birth of her child, two months ago. She reports finding it difficult to cope with the new baby and is overwhelmed by the baby's care. Patient admits to sleeping difficulties, including problems falling asleep after the baby, especially after the baby cries. She also reports reduced appetite, dissatisfaction with her body size and shape, low self-esteem, feelings of guilt and inadequacy, and avoiding contact with friends. She reports an irritable mood stating that "things just upset her." She also reports lack of interest in activities including writing, which she liked. Patient admits to having thoughts of suicide but has not acted upon them. She denies having thoughts of harming the baby. The patient is not currently prescribed any psychotropic medications. Past Psychiatric History: General Statement: Patient has never been assessed or treated for mental health disorders Caregivers (if applicable): n/a Hospitalizations: patient was recently hospitalized for normal childbirth Medication trials: None Psychotherapy or Previous Psychiatric Diagnosis: has no history of psychiatric illnesses and has never been treated for mental health conditions Substance Current Use and History: Patient denied alcohol or drug use Family Psychiatric/Substance Use History: Her uncle committed suicide using a GSW. Uncle was an opioid abuser Psychosocial History: patient is currently married and lives with her husband and two children. She is a stay-at-home mother after working in retail for 5 years. She grew up with both parents and has one sister who lives in Omaha, NE. she has a bachelor's degree in physics. She was employed in research science and worked as a high school teacher 5 years before the birth of her daughter. She had her first child two months ago. Client has no legal history Medical History: L.T has hypertension Current Medications: Labetalol 100 mg for HTN; admits to missing doses due to forgetting Allergies: Codeine Reproductive Hx: Gave birth two months ago and is currently lactating. She is currently not using contraceptives. Patient has not been sexually active since the birth of her child. She reports she has no drive or desire for sex ROS: General: no weight loss, chills, fever, or fatigue HEENT: Eyes: no changes in vision, double vision or jaundice. Ears, Nose, Throat: No changes in hearing, congestion, rhinorrhea or sore throat Skin: No changes in skin color. No rash or itching. Cardiovascular: No chest discomfort/pain, palpitations or edema Respiratory: No cough, sputum production or dyspnea Gastrointestinal: Reports reduced appetite. Reports she wants to lose weight after the pregnancy. No anorexia, vomiting or diarrhea. No abdominal pain Genitourinary: No burning with urination, hesitancy or urgency. No changes in urine color or odor Neurological: no headaches, seizures, paralysis, numbness or tingling in extremities Musculoskeletal: No back pain, joint pain or stiffness Hematologic: No bleeding or anemia Lymphatics: No enlarged nodes or history of splenectomy. Endocrinologic: no reports of sweating, heat or cold intolerance. No polydipsia or polyuria Objective: Vital signs: T- 97.6, P- 97, R 22, BP 149/98, Ht 5’3 Wt 245lb Physical exam: N/A Diagnostic results: N/A Assessment: Mental Status Examination: L.T is dressed appropriately for occasion and weather. She is alert and oriented to person, place, and time. Her memory appears to be intact during the assessment. She is cooperative but seems to be distant during assessment. Her speech is clear and coherent but she speaks in a low tone. Her mood is depressed. Affect is constricted. No delusions or hallucinations (both visual and auditory). Reports having thoughts of suicide or death but she has not acted upon them. Her insight and judgment are good Differential Diagnoses: Postpartum depression: This refers to an episode of depression with an onset of symptoms four weeks following delivery. It is epitomized by a depressed mood, excessive anxiety, changes in weight, and insomnia (Sadock et al., 2015). Associated stressors often include lack of support (Sadock et al., 2015). People with postpartum depression often present with other signs and symptoms of major depressive disorder including diminished pleasure in activities such as inappropriate guilt or inadequacy, thoughts of death or suicide in addition to thoughts of harming the baby (Sadock et al., 2015). This is the most likely diagnosis considering that the patient meets the diagnostic criteria for major depressive disorder and the symptoms started 4 weeks after childbirth. The client reports a depressed mood and crying almost every day, difficulty sleeping, reduced appetite, low self-esteem, feelings of guilt and inadequacy, lack of interest in pleasurable activities, and thoughts of suicide without a specific plan. Major depressive disorder: MDD is a mood disorder characterized by depressed mood or diminished pleasure in activities such as depressed mood. This includes feelings of sadness or tearfulness, lack of pleasure or interest in activities, insomnia or hypersomnia, weight loss, loss of energy, feelings of hopelessness or worthlessness, inappropriate guilt, frequent thoughts of suicide or death, loss of energy, and reduced ability to concentrate or indecisiveness (American Psychiatric Association, 2013). Even though the patient presents with most of these symptoms, it is less likely that this is the diagnosis given that the symptoms occurred within four weeks after delivery (APA, 2013). Postpartum blues: This is a transient mood disturbance that is characterized by low mood and mild depressive symptoms. These depressive symptoms include mood liability, dysphoria, crying, tearfulness, irritability, decreased sleep, and decreased concentration (Mullins, 2021). According to Sadock et al. (2015), the condition affects 30% to 50% of women who give birth. To meet the diagnostic criteria of the condition, the symptoms must occur 2-3 days of delivery and resolve within two weeks. If the symptoms persist for more than 2 weeks, the diagnostic criteria of major depressive disorder are met (Sadock et al., 2015). This is not the likely diagnosis because the symptoms persisted for more than 2 weeks Reflections Based on the presented case, I have learned the various mood disorders which can portray the same symptoms. Essentially, I have learned about postpartum depression, which is a mood disorder occurring 4-6 weeks after childbirth. I have also learned about other mood disorders, including major depressive disorder and postpartum blues, which mimic the symptoms of postpartum depression. To make an accurate diagnosis, it is essential to analyze factors related to stressors and triggers of the mood disorder (Sadock et al., 2015). A legal factor that should be considered during the treatment of the patient is drug safety, particularly in regards to the infant. The decision for a breastfeeding mother to take medications should involve careful considerations of the potential effectiveness of the drugs and potential risks to the infant. While all medications pass into breast milk, the extent of passage varies between drugs (Frieder et al.,2019). Also, given that patients with postpartum depression experience thoughts of suicide and harming the baby, it is important to ask about such thoughts to help determine if the thoughts are psychotic or obsessional as well as to help ensure the safety of the mother and child (Frieder et al.,2019) References American Psychiatric Association. (2013). DSM 5. American Psychiatric Association, 70. Frieder, A., Fersh, M., Hainline, R., & Deligiannidis, K. M. (2019). Pharmacotherapy of postpartum depression: current approaches and novel drug development. CNS drugs, 33(3), 265-282. Mullins IV, C. H. (2021). Postpartum Blues. Patient Education and Counseling. Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan & Sadock’s synopsis of psychiatry (11th ed.). Wolters Kluwer. Sherman, L. J., & Ali, M. M. (2018). Diagnosis of postpartum depression and timing and types of treatment received differ for women with private and Medicaid coverage. Women's Health Issues, 28(6), 524-529. 7 This study source was downloaded by 100000798758000 from CourseHero.com on 09-16-2021 12:13:21 GMT -05:00 https://www.coursehero.com/file/98069366/WK3Assgn1LinusO-Assessing-and-Diagnosing-Patients-with-Mood-Disorders-editeddocx/ This study resource was shared via Course NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Exemplar INSTRUCTIONS ON HOW TO USE EXEMPLAR AND TEMPLATE—READ CAREFULLY If you are struggling with the format or remembering what to include, follow the Comprehensive Psychiatric Evaluation Template AND the Rubric as your guide. It is also helpful to review the rubric in detail in order not to lose points unnecessarily because you missed something required. Below highlights by category are taken directly from the grading rubric for the assignment in Weeks 4–10. After reviewing the full details of the rubric, you can use it as a guide. In the Subjective section, provide: · Chief complaint · History of present illness (HPI) · Past psychiatric history · Medication trials and current medications · Psychotherapy or previous psychiatric diagnosis · Pertinent substance use, family psychiatric/substance use, social, and medical history · Allergies · ROS · Read rating descriptions to see the grading standards! In the Objective section, provide: · Physical exam documentation of systems pertinent to the chief complaint, HPI, and history · Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses. · Read rating descriptions to see the grading standards! In the Assessment section, provide: · Results of the mental status examination, presented in paragraph form. · At least three differentials with supporting evidence. List them from top priority to least priority. Compare the DSM-5 diagnostic criteria for each differential diagnosis and explain what DSM-5 criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case . · Read rating descriptions to see the grading standards! Reflect on this case. Include: Discuss what you learned and what you might do differently. Also include in your reflection a discussion related to legal/ethical considerations ( demonstrate critical thinking beyond confidentiality and consent for treatment !), health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.). (The comprehensive evaluation is typically the initial new patient evaluation. You will practice writing this type of note in this course. You will be ruling out other mental illnesses so often you will write up what symptoms are present and what symptoms are not present from illnesses to demonstrate you have indeed assessed for all illnesses which could be impacting your patient. For example, anxiety symptoms, depressive symptoms, bipolar symptoms, psychosis symptoms, substance use, etc.) EXEMPLAR BEGINS HERE CC (chief complaint): A brief statement identifying why the patient is here. This statement is verbatim of the patient’s own words about why presenting for assessment. For a patient with dementia or other cognitive deficits, this statement can be obtained from a family member. HPI: Begin this section with patient’s initials, age, race, gender, purpose of evaluation, current medication and referral reason. For example: N.M. is a 34-year-old Asian male presents for psychiatric evaluation for anxiety. He is currently prescribed sertraline which he finds ineffective. His PCP referred him for evaluation and treatment. Or P.H., a 16-year-old Hispanic female, presents for psychiatric evaluation for concentration difficulty. She is not currently prescribed psychotropic medications. She is referred by her therapist for medication evaluation and treatment. Then, this section continues with the symptom analysis for your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. First what is bringing the patient to your evaluation. Then, include a PSYCHIATRIC REVIEW OF SYMPTOMS. The symptoms onset, duration, frequency, severity, and impact. Your description here will guide your differential diagnoses. You are seeking symptoms that may align with many DSM-5 diagnoses, narrowing to what aligns with diagnostic criteria for mental health and substance use disorders. Past Psychiatric History: This section documents the patient’s past treatments. Use the mnemonic Go Cha MP. General Statement: Typically, this is a statement of the patients first treatment experience. For example: The patient entered treatment at the age of 10 with counseling for depression during her parents’ divorce. OR The patient entered treatment for detox at age 26 after abusing alcohol since age 13. Caregivers are listed if applicable. Hospitalizations: How many hospitalizations? When and where was last hospitalization? How many detox? How many residential treatments? When and where was last detox/residential treatment? Any history of suicidal or homicidal behaviors? Any history of self-harm behaviors? Medication trials: What are the previous psychotropic medications the patient has tried and what was their reaction? Effective, Not Effective, Adverse Reaction? Some examples: Haloperidol (dystonic reaction), risperidone (hyperprolactinemia), olanzapine (effective, insurance wouldn’t pay for it) Psychotherapy or Previous Psychiatric Diagnosis: This section can be completed one of two ways depending on what you want to capture to support the evaluation. First, does the patient know what type? Did they find psychotherapy helpful or not? Why? Second, what are the previous diagnosis for the client noted from previous treatments and other providers. Thirdly, you could document both. Substance Use History: This section contains any history or current use of caffeine, nicotine, illicit substance (including marijuana), and alcohol. Include the daily amount of use and last known use. Include type of use such as inhales, snorts, IV, etc. Include any histories of withdrawal complications from tremors, Delirium Tremens, or seizures. Family Psychiatric/Substance Use History: This section contains any family history of psychiatric illness, substance use illnesses, and family suicides. You may choose to use a genogram to depict this information. Be sure to include a reader’s key to your genogram or write up in narrative form. Social History: This section may be lengthy if completing an evaluation for psychotherapy or shorter if completing an evaluation for psychopharmacology. However, at a minimum, please include: Where patient was born, who raised the patient Number of brothers/sisters (what order is the patient within siblings) Who the patient currently lives with in a home? Are they single, married, divorced, widowed? How many children? Educational Level Hobbies: Work History: currently working/profession, disabled, unemployed, retired? Legal history: past hx, any current issues? Trauma history: Any childhood or adult history of trauma? Violence Hx: Concern or issues about safety (personal, home, community, sexual (current & historical) Medical History: This section contains any illnesses, surgeries, include any hx of seizures, head injuries. Current Medications: Include dosage, frequency, length of time used, and reason for use. Also include OTC or homeopathic products. Allergies: Include medication, food, and environmental allergies separately. Provide a description of what the allergy is (e.g., angioedema, anaphylaxis). This will help determine a true reaction vs. intolerance. Reproductive Hx: Menstrual history (date of LMP), Pregnant (yes or no), Nursing/lactating (yes or no), contraceptive use (method used), types of intercourse: oral, anal, vaginal, other, any sexual concerns ROS: Cover all body systems that may help you include or rule out a differential diagnosis. Please note: THIS IS DIFFERENT from a physical examination! You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe. Example of Complete ROS: GENERAL: No weight loss, fever, chills, weakness, or fatigue. 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: No rash or itching. CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema. RESPIRATORY: No shortness of breath, cough, or sputum. GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood. GENITOURINARY: Burning on urination, urgency, hesitancy, odor, odd color NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control. MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness. HEMATOLOGIC: No anemia, bleeding, or bruising. LYMPHATICS: No enlarged nodes. No history of splenectomy. ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia. Physical exam (If applicable and if you have opportunity to perform—document if exam is completed by PCP): From head to toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head-to-toe format i.e., General: Head: EENT: etc. Diagnostic results: Include any labs, X-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines). A ssessment Mental Status Examination: For the purposes of your courses, this section must be presented in paragraph form and not use of a checklist! This section you will describe the patient’s appearance, attitude, behavior, mood and affect, speech, thought processes, thought content, perceptions (hallucinations, pseudohallucinations, illusions, etc.)., cognition, insight, judgment, and SI/HI. See an example below. You will modify to include the specifics for your patient on the above elements—DO NOT just copy the example. You may use a preceptor’s way of organizing the information if the MSE is in paragraph form. He is an 8-year-old African American male who looks his stated age. He is cooperative with examiner. He is neatly groomed and clean, dressed appropriately. There is no evidence of any abnormal motor activity. His speech is clear, coherent, normal in volume and tone. His thought process is goal directed and logical. There is no evidence of looseness of association or flight of ideas. His mood is euthymic, and his affect appropriate to his mood. He was smiling at times in an appropriate manner. He denies any auditory or visual hallucinations. There is no evidence of any delusional thinking.   He denies any current suicidal or homicidal ideation. Cognitively, he is alert and oriented. His recent and remote memory is intact. His concentration is good. His insight is good.  Differential Diagnoses: You must have at least three differentials with supporting evidence. Explain what rules each differential in or out and justify your primary diagnosis selection. You will use supporting evidence from the literature to support your rationale. Include pertinent positives and pertinent negatives for the specific patient case. Also included in this section is the reflection. Reflect on this case and discuss whether or not you agree with your preceptor’s assessment and diagnostic impression of the patient and why or why not. What did you learn from this case? What would you do differently? Also include in your reflection a discussion related to legal/ethical considerations (demonstrating critical thinking beyond confidentiality and consent for treatment!), health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.). References (move to begin on next page) You are required to include at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines which relate to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting. © 2021 Walden University Page 1 of 3