PRAC 6635 Assignment 2: Comprehensive Psychiatric Evaluation and Patient Case Presentation
CC “I feel stuck”
HPI: GN is a 50 year old African American female who is here for a Mental health follow up evaluation. Client is recently divorced after 12 yeas of marriage, has 3 children between the ages of 12 and 23 and is living alone as her husband has custody of the younger children.
Client reports feeling down and depressed almost daily and having trouble falling and staying asleep. She reports feeling very anxious and scared and fearful, and is worried about her job and life in general. Client reports she is easily agitated and vey confrontational and over reacts to certain situations that she later realizes are minor issues. “I feel stuck, I feel like I lost my fire in life, my marriage failed, my job sucks, everyone tries to take advantage of me”.
Past Psychiatric History:
- General Statement: GN is a 50 year old African American female with a previous history of depression
- Caregivers : Client lives alone and has no caregivers
PRAC 6635 Assignment 2 Comprehensive Psychiatric Evaluation and Patient Case Presentation - Hospitalizations: No history of previous hospitilizations except for child bearing
- Medication trials: Wellbutrin 150-300mg (for 3 years from 2005)
- Psychotherapy or Previous Psychiatric Diagnosis: Hx. of Depression
Substance Current Use and History: Denies use of illicit drugs or ETOH abuse.
Family Psychiatric/Substance Use History: Son and Maternal Aunt with bipolar disorder
Psychosocial History: Client lives alone although she has 3 children who live with their father, including a 23 year
old son who chose to live with his father. She has a college degree and is currently employed as a sales representative in a large retail company. Client reports she was sexually abused by her cousin when she was 9 years old but was yelled at and called a liar when she tried to tell her family. Client reports being constantly teased as a child as she was overweight and emotionally abused by her cousins, siblings and mother. She reports she still feels a sense of guilt as she had a strained relationship with her mother that was never resolved prior to her mother’s death.
Medical History:
- Current Medications:
Mirtazpine 7.5 mg by mouth as needed at bedtime for insomnia.
Prozac 10 mg by mouth everyday for depression
Ferrous Sulpate 325 mg by mouth 3 times a day for anemia
Vitamin D 50000 iu by mouth weekly for vitamin D deficiency
- Allergies: No known drug or seasonal allergies
- Reproductive Hx: Menarche started at the age of 10, LMP 2 months ago, no abortions and miscarriages, currently not sexually active, 3 pregnancies and 3 living children.
ROS:
- GENERAL: Client is a 50 year old recently divorced AA female with a pevious hx. of depression.
- HEENT: The patient’s eyes appear normal. No abnormal discolorization of the sclera was observed. The ears are also normal. No sore throat or scratch. No sneezing and no cough.
- SKIN: no itchiness noted. The skin has no rashes, and no lesions were noted.
- CARDIOVASCULAR: No chest discomfort, no chest pressure or pain
- RESPIRATORY: no congestions nor respiratory issues were noted
- GASTROINTESTINAL: No nausea, vomiting,diarrhea,or abdominal pain. Client complains of poor appetite.
- GENITOURINARY: normal passing of urine with no pain, no hematuria
- NEUROLOGICAL: no numbness. No bowel movement changes or bladder control, no headache, dizziness or syncope.
- MUSCULOSKELETAL: Absence of joint pains, edema, and restricted movement in a range of motions
- HEMATOLOGIC: No bruises, bleeding, hx. of Iron deficiency anemia.
- LYMPHATICS: has no history of splenectomy and has no swollen lymph nodes
- ENDOCRINOLOGIC:No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.
Patient Health Questionnaire-9 (PHQ-9). Score is greater than 15
Diagnostic results: Major Depressive Disorder
Assessment
Mental Status Examination:
Client is well groomed, clean and overweight, appropriately dressed for the weather.She is calm, cooperative and pleasant with periods of tearfulness. Speech is clear, coherent and soft, client denies having any visual or auditory hallucinations, admits having suicidal ideations with no plans.
Cognition: A+O x 4, memory intact, intelligence average, memory remote, mood sad, affect anxious and tearful, insight and judgement intact, thought content unremarkable, motor activity intact.
Differential Diagnoses:
Major Depressive Disorder(MDD)
Bains, N. et al; (2021) reiterate the DSM-5 criteria for diagnosing MDD including a persistently low or depressed mood, anhedonia or decreased interest in pleasurable activities, feelings of guilt or worthlessness, lack of energy, poor concentration, appetite changes, psychomotor retardation or agitation, sleep disturbances, or suicidal thoughts and this client is experiencing all of these symptoms.
The DSM-5 specifier requires the presence of at least two of the five criterion symptoms for the majority of the depressive episode. The five symptoms of the anxious distress specifier are as follows: feeling keyed up or tense, feeling restless, difficulty concentrating because of worry, fear that something awful might happen, and feeling that one might lose control.( Zimmerman, M. et al; 2019).
Generalized Anxiety Disorder
GAD presents with excessive and unrealistic worry or anxiety. Other symptoms include: Restlessness or feeling keyed up or on edge, concentration difficulties, easy fatigue, muscle tension, irritability, and sleep disturbance (Bandelow et al., 2017).
Toussaint, A. et al; (2020) explain depression and anxiety are overlapping constructs and worry levels are comparable in individuals with GAD and depression. The clinical features of GAD according to Sadock, B. et al;( 2015) are sustained and extensive anxiety and worry accompanied by motor tension or restlessness, some features which are exhibited by this client, but persistent depression is the prevalent symptom presented in this client.
Post Traumatic Stress Disorder
PTSD occurs after one experiences the traumatic event directly, witnesses a
traumatic event as it occurs to others, or learns that a traumatic event happened to a
loved one (Miao et al; 2018).
There is no doubt that the traumatic event of being sexually abused as a young child has played a significant role in how this client experiences events, and contributed to her low self esteem, anxiety and vulnerability but this experience does not appear to be a constant stressor for this client, and would therefore not be considered as the first diagnosis.
Reflections:
This client obviously has deep seated issues that are yet to be resolved, including her claim that she was sexually abused by a close relative as a 9 year old impressionable child. According to Gilbert, P. (2019), when a child’s basic needs for protection, security, guided stimulation, and affection are lacking or even abused, the developmental trajectory is very different. Threat system processing dominates the construction of the self-identity, interpersonal attentional sensitivity, vulnerability to mental health problems, and antisocial behaviour.
Pharmacological agents have proved their efficacy in mental and behavioral issues, but with this client, I am of the opinion that she needs extensive psychotherapy that will give her the opportunity to explore her feelings, lay rest to unresolved issues in her life and guide her in appropriate ways to channel her energy and resolve issues that bother her.
Client is also complaining of difficulty falling and staying asleep, I would rather have her on a routine sleep agent than a PRN medication for now, as insomnia could lead to further complications. Life style changes like inculcating a moderate exercise program into her daily routine and seeking nutritional expertise to guide her and make dietary changes would be helpful as obesity can lead to several health complications and poor self esteem.
References
Bains N, Abdijadid S. Major Depressive Disorder. [Updated 2021 Apr 20]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK559078/
Bandelow, B., Michaelis, S., & Wedekind, D. (2017). Treatment of anxiety disorders. Dialogues in clinical neuroscience, 19(2), 93–107. https://doi.org/10.31887/DCNS.2017.19.2/bbandelow
Gilbert, P. (2019). Psychotherapy for the 21st century: An integrative, evolutionary, contextual, biopsychosocial approach. Psychology and Psychotherapy: Theory, Research and Practice, 92(2), 164-189.
Miao, X. R., Chen, Q. B., Wei, K., Tao, K. M., & Lu, Z. J. (2018). Post-traumatic stress disorder: from diagnosis to prevention. Military Medical Research, 5(1), 32. https://doi.org/10.1186/s40779-018-0179-0
Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan & Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry (Eleventh edition.). Philadelphia: Wolters Kluwer.
Toussaint, A., Hüsing, P., Gumz, A., Wingenfeld, K., Härter, M., Schramm, E., & Löwe, B. (2020). Sensitivity to change and minimal clinically important difference of the 7-item Generalized Anxiety Disorder Questionnaire (GAD-7). Journal of affective disorders, 265, 395-401.
Zimmerman, M., Martin, J., McGonigal, P., Harris, L., Kerr, S., Balling, C., … & Dalrymple, K. l(2019). Validity of the DSM‐5 anxious distress specifier for major depressive disorder. Depression and anxiety, 36(1), 31-38.