Last Updated on January 17, 2023 by Admin
Select a patient that you examined during the last 5 weeks
Comprehensive Psychiatric Evaluation and Patient Case Presentation
- Select a patient that you examined during the last 5 weeks. Review prior resources on the disorder this patient has.
- It is recommended that you use the Kaltura Personal Capture tool to record and upload your assignment.
- Review the Kaltura Media Uploader resource in the left-hand navigation of the classroom for help creating your self-recorded Kaltura Personal Capture video. The Personal Capture Quickstart Guide will walk you through creating your video, uploading it to Blackboard and placing it into the assignment area.
- Conduct a Comprehensive Psychiatric Evaluation on this patient using the template provided in the Learning Resources. There is also a completed exemplar document in the Learning Resources so that you can see an example of the types of information a completed evaluation document should contain. All psychiatric evaluations must be signed, and each page must be initialed by your Preceptor. When you submit your document, you should include the complete Comprehensive Psychiatric Evaluation as a Word document, as well as a PDF/images of each page that is initialed and signed by your Preceptor. You must submit your document 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 Late Policies.
- Develop a video case presentation, based on your progress note of this patient, that includes chief complaint; history of present illness; any pertinent past psychiatric, substance use, medical, social, family history; most recent mental status exam; and current psychiatric diagnosis, including differentials that were ruled out.
- Include at least five (5) 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 for your clinical patient. In your presentation:
- Dress professionally 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 case. Include chief complaint; history of present illness; any pertinent past psychiatric, substance use, medical, social, family history; most recent mental status exam; and current psychiatric diagnosis, including differentials that were ruled out.
- Report normal diagnostic results as the name of the test and “normal” (rather than specific value). Abnormal results should be reported as a specific value.
Be succinct in your presentation, and do not exceed 8 minutes. Address the following:
- Subjective: What details did the patient provide regarding their personal and medical history? What are their symptoms of concern? How long have they been experiencing them, and what is the severity? How are their symptoms impacting their functioning?
- Objective: What observations did you make during the interview and review of systems?
- Assessment: What were your differential diagnoses? Provide a minimum of three (3) possible diagnoses. List them from highest to lowest priority. What was your primary diagnosis, and why?
- Reflection notes: What would you do differently in a similar patient evaluation?
Expert Answer and Answer
SOAP Note for Major Depressive Disorder
CC (chief complaint): “I have been feeling quite low.”
HPI: GO is a 45-years-old African American female reporting to the clinic with a chief complaint of “I have been feeling quite low,” The patient reports that she started feeling that way a year ago but she doesn’t understand why. She got a job promotion about a year and a half ago in her marketing department which made her ecstatic.
However, she noted that with the pandemic, and lifting of the restrictions, they have been trying to catch up on the lost sales. She also states that it has been quite difficult to bring her best at her workplace, she feels fatigued as soon as the day starts, and rarely attends any social gatherings which she used to do quite often. She also reports a loss of appetite.
She reports that she has been under treatment for depression before when she lost her sister at 26 years and is currently relating that feeling with what she is currently experiencing.
Past Psychiatric History:
- General Statement: She has had treatment for depression previously at 26 years.
- Caregivers: No caregivers.
- Hospitalizations: Never hospitalized for any psychiatric conditions. Denies ever having suicidal ideations
- Medication trials: Never participated in medical trials.
- Psychotherapy or Previous Psychiatric Diagnosis: Previously diagnosed with depression at 26
Substance Current Use and History: Denies using any tobacco and associated products. Drinks a glass of wine at least four times a week up from a glass of wine per session, two when hanging out with friends, at most twice a week. Denies use of any other illicit drugs or substances.
Family Psychiatric/Substance Use History: Denies family history of substance use or mental health problems.
Psychosocial History: Pt. was born and grew up in Chicago, but moved to Los Angeles, California five years ago where she currently resides. She is a single mother, with an 18-year-old daughter, whom she says is in a stage that makes her “crazy.” She has a partner whom she has been seeing for a year. Both parents are alive, the father is currently 76 years, and the mother is 70.
Both are hypertensive but well controlled with medications. She is the eldest sibling in a family of four. Her two brothers are 36 and 28. Her sister died from a road accident at the age of 22 years. She stopped her Master’s program three months ago due to her current busy schedule but expects to resume when things normalize.
Medical History: No underlying mental problem.
- Current Medications: Not under any psychiatric medications. Uses ibuprofen for her headaches.
- Allergies: No allergies.
- Reproductive Hx: Sexually active with one partner. No reproductive abnormalities.
- GENERAL: Reports fatigue, frequent headache, weakness, loss of appetite, and weight loss. Denies having any fever.
- HEENT: Non-contributory.
- SKIN: Denies skin dryness, rashes, or itching
- CARDIOVASCULAR: Denies having any chest discomfort or pain
- RESPIRATORY: Denies having breathing difficulties or shortness of breath.
- GASTROINTESTINAL: Denies feeling nauseated, abdominal pain, diarrhea, or constipation.
- GENITOURINARY: Denies having any GU symptoms.
- NEUROLOGICAL: Denies neurological symptoms.
- MUSCULOSKELETAL: Denies joint or muscle abnormalities, pain, or discomfort
- HEMATOLOGIC: Denies bruising.
- LYMPHATICS: Negative for splenectomy.
- ENDOCRINOLOGIC: Denies any endocrinologic abnormalities.
Vital Signs: T 36.5, HR 78, BP 110/88, Ht. 5’7 Wt. 67kgs, RR 18.
- HEENT: Head: Non-contributory.
- Skin: Warm, no rash, and dry., no tenting.
- CV: No bruits, murmurs, chest clear to osculation, no chest swelling. Regular heart rate and rhythm.
- Respiratory: No respiratory distress. No wheezing sound was noted on auscultation.
The diagnostic tool that was used to assess the patient is the Hopkins Symptoms Checklist with 25 items (HSCL-25), which is a valid tool that is used to assess for both anxiety and depression (Vindbjerg et al., 2021). The diagnostic score returned indicated that the patient is currently experiencing depression.
Mental Status Examination: The patient was oriented to time, place, and event. Dressed appropriately with respect to the weather. The patient managed to express herself eloquently throughout the interview. She maintained eye contact throughout the session. She denied having any suicidal ideations. She also reports poor concentration and low energy at work. She confirms losing interest in most of her social activities and feels like needing some time alone quite often. She also denies having any delusional thoughts or paranoia.
Based on the patient’s symptoms, the following are some of the differential diagnoses;
- Recurrent MDD DSM-5 (296.99 (F34.8)
- Major depressive disorder (MDD) DSM-5 296.33 (F33.2)
- Adjustment disorder with depressed features DSM-5 (309.0 (F43. 21)
The primary diagnosis is recurrent MDD. Major depressive disorder also referred to as clinical depression is a mood-related disorder characterized by a feeling of sadness, loss of sleep and appetite, fatigue, reduced productivity in routine activities, and loss of interest in social events (Bains & Abdijadid, 2021). The condition has a significant impact on one’s functional, physical and psychological wellbeing.
The condition is selected over the other two because of various reasons. One of the reasons is that the patient had a previous diagnosis of MDD, which makes her qualify for recurrent MDD as per Lye et al. (2020) who state that the diagnosis of recurrent MDD is made when a patient experiences symptoms after at least 2 consecutive months between distinct episodes.
In addition, diagnosis for 3. Adjustment disorder with depressed features was rejected given that the patient had experienced depressive symptoms for more than six months (APA, 2013).
This case presents a patient with symptoms aligning with depression based on the collected subjective data. The observations are confirmed with the diagnostic tests performed using HSCL-25, and the objective data collected that informed the preceptor’s diagnosis which I agree with.
At first, I was inclined to think that the condition fits adjustment disorder given the patient’s new job promotion, however, the duration of the symptoms transitioned to major depressive disorder. One of the ethical considerations in a case such as this is to ensure patient confidentiality is protected. This will allow the patient to share pertinent information which can prove useful in providing an effective treatment regimen.
Case Formulation and Treatment Plan:
The patient presents symptoms aligning with recurrent MDD. The treatment regimen should consist of both behavioral and pharmacotherapeutic approaches for increased efficacy. I would propose that the patient be given a prescription for Zoloft The patient should also be instructed to cease her intake of alcohol during the treatment period to avoid adverse reactions and to prevent the risk of addiction (McHugh & Weiss, 2019).
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Author.
Bains, N., & Abdijadid, S. (2021). Major depressive disorder. In StatPearls [Internet]. StatPearls Publishing.
Lye, M. S., Tey, Y. Y., Tor, Y. S., Shahabudin, A. F., Ibrahim, N., Ling, K. H., Stanslas, J., Loh, S. P., Rosli, R., Lokman, K. A., Badamasi, I. M., Faris-Aldoghachi, A., & Abdul Razak, N. A. (2020). Predictors of recurrence of major depressive disorder. PloS one, 15(3), e0230363. https://doi.org/10.1371/journal.pone.0230363
McHugh, R. K., & Weiss, R. D. (2019). Alcohol Use Disorder and Depressive Disorders. Alcohol research: current reviews, 40(1), arcr.v40.1.01. https://doi.org/10.35946/arcr.v40.1.01
Vindbjerg, E., Mortensen, E. L., Makransky, G., Nielsen, T., & Carlsson, J. (2021). A Rasch-based validity study of the HSCL-25. Journal of Affective Disorders Reports, 4, 100096.
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