Assignment 2: Comprehensive Psychiatric Evaluation Note and Patient Case Presentation
- Review this week\’s Learning Resources and consider the insights they provide about clinical practice guidelines.
- Select a group patient for whom you conducted psychotherapy for a mood disorder during the last 4 weeks. Create a Comprehensive Psychiatric Evaluation Note on this patient using the template provided in the Learning Resources. There is also a completed template provided as an exemplar and guide. All psychiatric evaluation notes must be signed, and each page must be initialed by your Preceptor. When you submit your note, you should include the complete comprehensive psychiatric evaluation note as a Word document and pdf/images of each page that is initialed and signed by your Preceptor. You must submit your note using SafeAssign.Please Note: Electronic signatures are not accepted. If both files are not received by the due date, Faculty will deduct points per the Walden Grading Policy.
- Then, based on your evaluation of this patient, develop a video presentation of the case. Plan your presentation using the Assignment rubric and rehearse what you plan to say. Be sure to review the Kaltura Media Uploader resource in the left-hand navigation of the classroom for help creating your self-recorded Kaltura video.
- Include at least five scholarly resources to support your assessment and diagnostic reasoning.
- Ensure that you have the appropriate lighting and equipment to record the presentation.
Record yourself presenting the complex case study for your clinical patient. In your presentation:
- Dress professionally with a lab coat and present yourself in a professional manner.
- Display your photo ID at the start of the video when you introduce yourself.
- Ensure that you do not include any information that violates the principles of HIPAA (i.e., don’t use the patient’s name or any other identifying information).
- Present the full complex case study. Be succinct in your presentation, and do not exceed 8 minutes. Include subjective and objective data; assessment from most recent mental status exam; current psychiatric diagnosis including differentials that were ruled out; current psychotherapeutic plan (include one health promotion activity and one patient education strategy you provided); and patient progress toward treatment goals.
- Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What was the duration and severity of their symptoms? How are their symptoms impacting their functioning in life?
- Objective: What observations did you make during the psychiatric assessment?
- Assessment: Discuss the patient’s mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses in order of highest to lowest priority and explain why you chose them. What was your primary diagnosis and why? Describe how your primary diagnosis aligns with DSM-5 diagnostic criteria and is supported by the patient’s symptoms.
- Plan: What was your plan for psychotherapy (including one health promotion activity and one patient education strategy)? What was your plan for treatment and management, including alternative therapies? Include nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.
- Reflection notes: What would you do differently with this patient if you could conduct the session again?
Expert Answer and Explanation
CC (“feeling depressed”):
HPI: JJ is a 36-year-old Asian American male who reports to the clinic for an initial visit with a chief complaint of depression. The patient notes that he has been feeling that way for six months now. He also reports diminished sleep which started 5 months ago and has gradually worsened since then. He also cites lack of sleep as a contributing factor to low concentration and efficiency at his workplace, which has become notable by his seniors. The patient also notes that he has become disinterested in social events and has since stopped going to church. Instead, he prefers to be alone. The patient reports using Zoloft 50 mg PO qDay, which he notes to have stopped working about a month ago.
Past Psychiatric History:
- General Statement: The patient has had a previous counseling session for depression after having lost her wife a year and a half ago
- Caregivers (if applicable):
- Hospitalizations: The patient has not been hospitalized before for any mental disorders. The patient also denies having any history of suicidal ideations or self-harm behaviors.
- Medication trials: The patient has had a previous prescription of Zoloft 50 mg PO qDay, which he notes to have stopped working about two months ago.
- Psychotherapy or Previous Psychiatric Diagnosis: The patient has previously tried to engage in suggested psychotherapy, including the use of meditation but he notes that he has never been patient enough to consistently practice the approach.
Substance Current Use and History: The patient states that he smokes cigarettes approximately three to four sticks every day, and his habit has since worsened since he started feeling depressed. He used to drink but stopped three years ago and has never engaged in alcohol since then. He notes that he has never tried enrolling in any smoking cessation program but he desires to quit since he understands the harmful effects smoking has on his health.
Family Psychiatric/Substance Use History: The patient’s grandfather used to drink but had great tolerance to alcohol as noted. The parents were avid Christians who never encouraged the use of any substance. The patient’s eldest brother smokes cigarettes (between 3 t 5 sticks daily) and also drinks alcohol mainly during the weekend. The family has never had any history of suicides or psychiatric illness.
Psychosocial History: The patient was born in the U.S after his parents and grandparents migrated from China for employment opportunities forty years ago. The parents have since then become full citizens, granting JJ citizenship by birth. The patient was raised by his parents who were always there for him, after which, he married a White, who unfortunately died after a long struggle with cancer just over a year ago.
The patient only has one elder brother, with both parents still being alive. Currently, the patient is widowed and lives alone. He has not been interested in looking for a partner since his wife died. He doesn’t have any children yet.
JJ graduated three years ago with an undergraduate degree in civil engineering and currently works with a construction company as a resident engineer and a project manager. However, recently his performance and concentration at work have been gradually reducing. Some of his hobbies are biking, hiking, and reading. Before his wife died, they used to go out and have fun with friends at least every weekend, but since then his social habits have greatly changed.
Recently, he had a minor accident, where he bumped into a car but managed to solve the issue amicably. He notes that he cannot explain what happened exactly. Otherwise, he had not had any recent engagements with law enforcement. JJ also reports he has never had any noteworthy trauma during his childhood, noting that he had a fairly normal upbringing.
Violence Hx: the patient reported no history of violence.
Medical History: The patient has previously had an appendectomy when he was 20 years.
- Current Medications: Zoloft 50 mg PO qDay
- Allergies: No food, drug, or seasonal allergies
- Reproductive Hx: The patient notes his sexual orientation as straight, but has not engaged in any form of sexual intercourse within the past 2 months.
- GENERAL: Weight loss of 6 pounds in two months, no fever, chills, or weakness reported. The patient however appears to be lethargic.
- HEENT: No visual loss, blurred vision, double vision, or yellow sclerae. No hearing loss, sneezing, congestion, runny nose, or sore throat, Voice sounds scratchy.
- CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema were noted.
- RESPIRATORY: No sputum, cough, wheezing sound, or shortness of breath.
- NEUROLOGICAL: Mild headache, no dizziness or syncope,
Physical exam: N/A
Diagnostic results: The diagnostic test needed for this to assess whether the patient has depression is a Montgomery- Asberg Depression Rating Scale (MADRS). According to Hengartner et al. (2020), MADRS is considered a gold standard for diagnosing patients suspected of having depression. MADRS helps to assess whether a patient has depression and the severity of the disease.
Mental Status Examination: The patient is a 36-year-old Asian American male. He appears to be well dressed and constituted during the exams. He does not consistently maintain eye contact during the exams. He answers all questions appropriately and he is well oriented to both time, place, event. and person. He denies having any suicidal ideation, self-harm, delusional, or paranoid thoughts.
Based on the assessment of the patient, the three differentials include;
- Major Depressive disorder (primary)
- Bipolar Disorder
- Adjustment disorder with depressed mood
- Borderline personality disorder
The primary diagnosis for the selected case is major depressive disorder. The symptoms presented in the case appear to be synonymous with the DSM IV manual on mental disorders. According to the American Psychiatric Association. (2013). DSM-IV manual, major depressive episode occurs when an individual has 5 or more depressive symptoms for more than two weeks. Some of the symptoms JJ portrays that links to depression include; depressed mood, diminished interest in social activities, insomnia, diminished ability to concentrate, and feeling fatigued. Due to these factors, major depressive disorder was considered as the primary diagnosis
The second diagnosis is bipolar disorder. Bipolar disorder is a condition characterized by manic episodes and low depressive episodes (Vieta et al., 2018). However, given that the patient did not report or show any signs of manic episodes, then it is eliminated as the primary diagnosis. Adjustment disorder with depressed mood is another possible diagnosis that could be linked to the patient having lost his wife, and also matches with the onset of the depression. The symptoms presented by JJ also meet the DSM-IV criteria of adjustment disorder with depressed mood. The last diagnosis is borderline personality disorder, which is associated with emotional instability and can make one have bouts of depression (Scott et al., 2017). However, the patient does not meet the criteria of the disorder as per the DSM-IV manual.
The case presents an Asian American patient with symptoms aligning with those of major depressive disorder. Based on the presented facts, I agree with my preceptor’s analysis of the case. The DSM-IV manual highlights some of the aspects that qualify one to be diagnosed with major depressive disorder. Some of these aspects include having a depressed mood, diminished interest in social events, insomnia, reduced ability to concentrate, and feeling fatigued (American Psychiatric Association., 2013), which makes me agree with the diagnosis. Results of the MADRS will further clarify whether the patient has depression and the severity of the disorder. From this case, I learned that depression can impair one’s optimal functionality and without guided evidence-based interventions, it is difficult for a patient to return to optimal functioning. I would
Some of the ethical considerations involved in this case include weighing the benefits of therapeutic approaches in conformance with ethical principles of maleficence and beneficence. As noted by Wang et al. (2018), some of the anti-depressants that can be used to assist the patient have serious side effects. Therefore the care professional should weigh the pros and cons and alternative interventions before prescribing. Following the same ethical principle, the patient should be encouraged to have gene testing, specifically for the CYP2D6 allele that has an impact on drug metabolism. According to Milosavljević et al. (2020), variation in the CYP2D6 allele has an impact on the metabolism of antidepressants and antipsychotics. Other studies noting that Asians have a higher prevalence of the mutation, thus having an impact on antidepressant prescriptions (Bagheri et al., 2015)
The health promotion initiatives that will be recommended to the patient include health promotion on smoking cessation, including identification of resources that will help the patient quit. Another health promotion opportunity is o physical exercises which are known to have a therapeutic effect that can assist patients with depression to have improvements in terms of coping.
American Psychiatric Association. (2013). Dissociative disorders. In Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author. doi:10.1176/appi.books.9780890425596.dsm08
Bagheri, A., Kamalidehghan, B., Haghshenas, M., Azadfar, P., Akbari, L., Sangtarash, M. H., Vejdandoust, F., Ahmadipour, F., Meng, G. Y., & Houshmand, M. (2015). Prevalence of the CYP2D6*10 (C100T), *4 (G1846A), and *14 (G1758A) alleles among Iranians of different ethnicities. Drug design, development, and therapy, 9, 2627–2634. https://doi.org/10.2147/DDDT.S79709
Hengartner, M. P., Jakobsen, J. C., Sørensen, A., & Plöderl, M. (2020). Efficacy of new-generation antidepressants assessed with the Montgomery-Asberg Depression Rating Scale, the gold standard clinician rating scale: A meta-analysis of randomized placebo-controlled trials. PLoS One, 15(2), e0229381. https://doi.org/10.1371/journal.pone.0229381
Milosavljević, F., Bukvić, N., Pavlović, Z., Miljević, Č., Pešić, V., Molden, E., … & Jukić, M. M. (2020). Association of CYP2C19 and CYP2D6 poor and intermediate metabolizer status with antidepressant and antipsychotic exposure: a systematic review and meta-analysis. JAMA Psychiatry. doi:10.1001/jamapsychiatry.2020.3643
Scott, L. N., Wright, A. G., Beeney, J. E., Lazarus, S. A., Pilkonis, P. A., & Stepp, S. D. (2017). Borderline personality disorder symptoms and aggression: A within-person process model. Journal of Abnormal Psychology, 126(4), 429.
Vieta, E., Salagre, E., Grande, I., Carvalho, A. F., Fernandes, B. S., Berk, M., & Suppes, T. (2018). Early intervention in bipolar disorder. American Journal of Psychiatry, 175(5), 411-426. https://doi.org/10.1176/appi.ajp.2017.17090972
Wang, S. M., Han, C., Bahk, W. M., Lee, S. J., Patkar, A. A., Masand, P. S., & Pae, C. U. (2018). Addressing the side effects of contemporary antidepressant drugs: a comprehensive review. Chonnam Medical Journal, 54(2), 101-112. https://doi.org/10.4068/cmj.2018.54.2.101
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