Case Study For Patient Complaining Of Depression Discussion

Case Study For Patient Complaining Of Depression Discussion

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Subjective:

CC (chief complaint): : “I’m feeling extremely down and hopeless lately.”

HPI: Mr. K.N., a 25-year-old Caucasian male, presents with a chief complaint of persistent feelings of depression. The patient reports a gradual onset of symptoms that have been present for the past six months. He explains that his mood has been consistently low, characterized by feelings of sadness, emptiness, and hopelessness. K.N. mentions that he has lost interest and pleasure in activities he used to enjoy, including hobbies, socializing, and spending time with loved ones. He describes feeling fatigued and lacking energy throughout the day, often struggling to get out of bed in the morning. K.N. admits to experiencing significant changes in appetite, with a noticeable decrease leading to unintentional weight loss. He also mentions difficulty sleeping, often finding it hard to fall asleep or experiencing disturbed sleep patterns with frequent awakenings during the night. He acknowledges having trouble concentrating, making decisions, and experiencing a decline in his overall cognitive abilities. The patient states that he has been isolating himself from others, avoiding social interactions, and prefers to spend most of his time alone. He expresses a sense of guilt and worthlessness, questioning his self-esteem and feeling like a burden to those around him. K.N. denies any history of suicidal thoughts or self-harm but admits to having occasional fleeting thoughts of “life not being worth living.” K.N. reports that these symptoms have started to impact his personal and professional life. He mentions a decline in work performance, increased absenteeism, and strained relationships with colleagues. He states that he finds it difficult to experience joy or excitement, and overall, his quality of life has significantly diminished Case Study For Patient Complaining Of Depression Discussion.

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Substance Current Use: denies any current substance use, including alcohol, tobacco, and illicit drugs.

Medical History: No significant medical history reported. The patient has not been diagnosed with any chronic medical conditions or previous hospitalizations

• Current Medications: Patient is not currently taking any prescribed medications or over-the-counter drugs.
• Allergies: NKA

• Reproductive Hx: reports no reproductive concerns.

ROS:

• GENERAL: Reports decreased energy levels, feelings of fatigue, and a decline in overall motivation.
• HEENT: No recent changes in vision, hearing, or sinus issues.
• SKIN: No skin rashes, lesions, or abnormalities noted.
• CARDIOVASCULAR: No chest pain, palpitations, or shortness of breath.
• RESPIRATORY: No cough, wheezing, or respiratory difficulties.
• GASTROINTESTINAL: Denies any gastrointestinal symptoms such as abdominal pain, nausea, or changes in bowel habits.
• GENITOURINARY: No urinary symptoms or concerns.
• NEUROLOGICAL: Reports difficulty with concentration and decision-making abilities.
• MUSCULOSKELETAL: No joint pain, stiffness, or musculoskeletal complaints.
• HEMATOLOGIC: No history of bleeding disorders or abnormal blood clotting.
• LYMPHATICS: No swelling, tenderness, or enlargement of lymph nodes.
• ENDOCRINOLOGIC: No known endocrine disorders or symptoms related to hormonal imbalances

Objective: N/A

Diagnostic results: PHQ-9 Score: 20

Assessment:

Mental Status Examination: During the assessment, Mr. K.N. presents with a dysphoric affect, appearing visibly sad and emotionally labile. He exhibits psychomotor retardation, with slowed movements and a lack of energy. His speech is slow and monotonous. Mr. K.N. demonstrates impaired concentration and decreased attention span, struggling to maintain focus during the conversation. He expresses feelings of worthlessness, guilt, and hopelessness. No hallucinations or delusions are noted. Insight into his condition is present, as he acknowledges the impact of his symptoms on his personal and professional life Case Study For Patient Complaining Of Depression Discussion.

Diagnostic Impression:

1. Major Depressive Disorder (MDD): My primary diagnosis for Mr. K.N. is Major Depressive Disorder (MDD). It is a condition characterized by persistent feelings of sadness, loss of interest or pleasure in activities, and a range of other emotional and physical symptoms (Bains & Abdijadid, 2022). This diagnosis aligns with the patient’s chief complaint and symptoms, including persistent low mood, loss of interest in pleasurable activities, significant changes in appetite and weight, difficulty sleeping, impaired concentration, feelings of guilt and worthlessness, and a decline in overall functioning. These symptoms meet the criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) for MDD. The severity of his symptoms, as indicated by the PHQ-9 score of 20, suggests a moderately severe level of depression.
2. Adjustment Disorder with Depressed Mood: This is a condition characterized by the development of depressive symptoms in response to a significant life stressor or event (O’Donnell et al., 2019). This diagnosis could be considered if there is evidence of a stressor or life event that triggered the onset of depressive symptoms. However, based on the information provided, there is no mention of a specific stressor or life event contributing to Mr. K.N.’s symptoms. Therefore, this diagnosis is of lower priority.
3. Dysthymic Disorder (Persistent Depressive Disorder): Dysthymic Disorder, also known as Persistent Depressive Disorder, could be considered as a possible diagnosis. This disorder involves a chronic, persistent depressive mood for at least two years (Patel & Rose, 2021). However, the gradual onset of symptoms over the past six months and the presence of significant functional impairment align more closely with the criteria for Major Depressive Disorder. Therefore, Dysthymic Disorder is of lower priority in this case.

Reflections: If I could conduct the session again, I would place more emphasis on exploring Mr. K.N.’s social support system and evaluating the impact of his relationships on his mental health. Additionally, I would discuss potential lifestyle modifications, such as improving sleep hygiene and incorporating healthy dietary habits, as adjunctive strategies to enhance treatment outcomes. Unfortunately, since I cannot conduct a follow-up session, I will anticipate assessing Mr. K.N.’s response to treatment during subsequent visits. If the interventions prove successful, I would continue to monitor his progress and make any necessary adjustments. However, if the interventions were not successful, I would consider the need for a higher level of care, such as referral to a specialized mental health facility or consultation with a psychiatrist for further assessment and potential modification of the treatment plan.

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Case Formulation and Treatment Plan:

Mr. K.N.’s case suggests a primary diagnosis of Major Depressive Disorder (MDD). It is likely that a combination of genetic vulnerability, as evidenced by a family history of depression, and psychosocial factors contribute to the development of his depressive symptoms. The patient’s gradual onset of symptoms, significant functional impairment, and the absence of specific stressors point towards an endogenous etiology.

Treatment Plan: Case Study For Patient Complaining Of Depression Discussion

1. Psychotherapy: Individual Cognitive-Behavioral Therapy (CBT) to address negative thinking patterns and develop coping strategies (Gautam et al., 2020).
2. Medication: Initiate an SSRI antidepressant, such as escitalopram or sertraline, with regular follow-up to assess response and adjust if needed.

Alternative Treatments:

1. Exercise: Encourage regular aerobic activities or yoga to improve mood and well-being.
2. Mindfulness-Based Therapy: Consider mindfulness-based interventions like MBCT or MBSR to reduce depressive symptoms.

Follow-Up Plan: Follow-up in 4-6 weeks to monitor progress, adjust treatment, and assess medication tolerability.

Referrals: Consider referral to a psychiatrist or mental health specialist for comprehensive evaluation and collaboration with a licensed therapist or psychologist specializing in evidence-based psychotherapies.

Social Determinant of Health: Education plays a role in mental health outcomes. Consider Mr. K.N.’s education level and its impact on engagement in treatment and navigating the healthcare system.

Health Promotion Activity: Implement community outreach programs and mental health awareness campaigns to reduce stigma, increase access to resources, and promote early intervention.

Patient Education Consideration: Provide education on depression, its treatment options, and the importance of seeking help.

PRECEPTOR VERFICIATION:

I confirm the patient used for this assignment is a patient that was seen and managed by the student at their Meditrek approved clinical site during this quarter course of learning.

Preceptor signature: Case Study For Patient Complaining Of Depression Discussion ________________________________________________________

Date: ________________________

 References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

Bains, N., & Abdijadid, S. (2022). Major depressive disorder. In StatPearls [Internet]. StatPearls Publishing.

Gautam, M., Tripathi, A., Deshmukh, D., & Gaur, M. (2020). Cognitive behavioral therapy for depression. Indian journal of psychiatry, 62(Suppl 2), S223.

O’Donnell, M. L., Agathos, J. A., Metcalf, O., Gibson, K., & Lau, W. (2019). Adjustment disorder: Current developments and future directions. International journal of environmental research and public health, 16(14), 2537.

Patel, R. K., & Rose, G. M. (2021). Persistent Depressive Disorder. In StatPearls [Internet]. StatPearls Publishing.

INSTRUCTIONS ON HOW TO USE EXEMPLAR AND TEMPLATE—READ CAREFULLY

If you are struggling with the format or remembering what to include, follow the Focused SOAP Note 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.  After reviewing full details of the rubric, you can use it as a guide.

In the Subjective section, provide: Case Study For Patient Complaining Of Depression Discussion

• 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-TR diagnostic criteria for each differential diagnosis and explain what DSM-5-TR 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!), social determinates of health, 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 FOCUSED SOAP psychiatric evaluation is typically the follow-up visit patient note. You will practice writing this type of note in this course. You will be focusing more on the symptoms from your differential diagnosis from the comprehensive psychiatric evaluation narrowing to your diagnostic impression. You will write up what symptoms are present and what symptoms are not present from illnesses to demonstrate you have indeed assessed for illnesses which could be impacting your patient. For example, anxiety symptoms, depressive symptoms, bipolar symptoms, psychosis symptoms, substance use, etc.)Case Study For Patient Complaining Of Depression Discussion

EXEMPLAR BEGINS HERE

Subjective:

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 medication management follow up for anxiety. He was initiated sertraline last appt which he finds was effective for two weeks then symptoms began to return.

Or

P.H., a 16-year-old Hispanic female, presents for follow up to discuss previous psychiatric evaluation for concentration difficulty. She is not currently prescribed psychotropic medications as we deferred until further testing and screening was conducted.

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 follow up evaluation? Document symptom onset, duration, frequency, severity, and impact. What has worsened or improved since last appointment? What stressors are they facing? Your description here will guide your differential diagnoses into your diagnostic impression. 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 Case Study For Patient Complaining Of Depression Discussion.

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.

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 Case Study For Patient Complaining Of Depression Discussion.

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.

Objective:

Diagnostic results: Include any labs, X-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines)Case Study For Patient Complaining Of Depression Discussion.

Assessment:

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 Case Study For Patient Complaining Of Depression Discussion.

Diagnostic Impression: You must begin to narrow your differential diagnosis to your diagnostic impression.  You must explain how and why (your rationale) you ruled out any of your differential diagnoses. You must explain how and why (your rationale) you concluded to your diagnostic impression.  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!), social determinates of health, 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.)Case Study For Patient Complaining Of Depression Discussion.

Case Formulation and Treatment Plan

Includes documentation of diagnostic studies that will be obtained, referrals to other health care providers, therapeutic interventions including psychotherapy and/or psychopharmacology, education, disposition of the patient, and any planned follow-up visits. Each diagnosis or condition documented in the assessment should be addressed in the plan. The details of the plan should follow an orderly manner.  *See an example below. You will modify to your practice so there may be information excluded/included. If you are completing this for a practicum, what does your preceptor document?

Risks and benefits of medications are discussed including non- treatment. Potential side effects of medications discussed (be detailed in what side effects discussed). Informed client not to stop medication abruptly without discussing with providers. Instructed to call and report any adverse reactions. Discussed risk of medication with pregnancy/fetus, encouraged birth control, discussed if does become pregnant to inform provider as soon as possible. Discussed how some medications might decreased birth control pill, would need back up method (exclude for males).

Discussed risks of mixing medications with OTC drugs, herbal, alcohol/illegal drugs. Instructed to avoid this practice. Encouraged abstinence. Discussed how drugs/alcohol affect mental health, physical health, sleep architecture.

Initiation of (list out any medication and why prescribed, any therapy services or referrals to specialist):

Client was encouraged to continue with case management and/or therapy services (if not provided by you)

Client has emergency numbers:  Emergency Services 911, the  Client’s Crisis Line 1-800-_______. Client instructed to go to nearest ER or call 911 if they become actively suicidal and/or homicidal. (only if you or preceptor provided them)

Reviewed hospital records/therapist records for collaborative information; Reviewed PMP report (only if actually completed)

Time allowed for questions and answers provided. Provided supportive listening. Client appeared to understand discussion. Client is amenable with this plan and agrees to follow treatment regimen as discussed. (this relates to informed consent; you will need to assess their understanding and agreement) Case Study For Patient Complaining Of Depression Discussion

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Follow up with PCP as needed and/or for:

Labs ordered and/or reviewed (write out what diagnostic test ordered, rationale for ordering, and if discussed fasting/non fasting or other patient education)

Return to clinic:

Continued treatment is medically necessary to address chronic symptoms, improve functioning, and prevent the need for a higher level of care.

 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 Case Study For Patient Complaining Of Depression Discussion

Select a patient of any age (either a child or an adult) that you examined during the last 3 weeks.
Create a Focused SOAP Note on this patient using the template provided in the Learning Resources. There is also a completed Focused SOAP Note Exemplar provided to serve as a guide to assignment expectations.

Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What is 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 their mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses and why you chose them. List them from highest priority to lowest priority. What was your primary diagnosis and why? Describe how your primary diagnosis aligns with DSM-5 diagnostic criteria and supported by the patient’s symptoms.
Plan: In your video, describe your treatment plan using clinical practice guidelines supported by evidence-based practice. Include a discussion on your chosen FDA-approved psychopharmacologic agents and include alternative treatments available and supported by valid research. All treatment choices must have a discussion of your rationale for the choice supported by valid research. What were your follow-up plan and parameters? What referrals would you make or recommend as a result of this treatment session?
In your written plan include all the above as well as include one social determinant of health according to the HealthyPeople 2030 (you will need to research) as applied to this case in the realm of psychiatry and mental health. As a future advanced provider, what are one health promotion activity and one patient education consideration for this patient for improving health disparities and inequities in the realm of psychiatry and mental health? Demonstrate your critical thinking.
Reflection notes: What would you do differently with this patient if you could conduct the session again? If you are able to follow up with your patient, explain whether these interventions were successful and why or why not. If you were not able to conduct a follow up, discuss what your next intervention would be.