Psychopathology And Diagnostic Reasoning Assignment Discussion

Psychopathology And Diagnostic Reasoning Assignment Discussion

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Fill out the attached template in its entirety using the case study and video for more information. See RUBRIC attached as well as exemplar template. Complete all the tabs in the review of systems on the template. Use 4 pages to complete this template. Provide at least references dated within the last 5 years APA 7th edition format. Give an introduction, purpose, and conclusion Psychopathology And Diagnostic Reasoning Assignment Discussion.

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Introduction

A Subjective, Objective, Assessment, and Plan is among the most common forms of documentation used to input notes into the medicalrecords of a patient. This SOAP note will allow a provider to both record and share information about a psychiatric patient in an easy to read and systematic format. The patient in question has been diagnosed with depression in the past. However, this SOAP note will also provide differential diagnoses basedon the patient’s prevailing symptoms. The purpose of this SOAP note therefore is to provide a diagnosis for the patient thereby allowing the relevant health care practitioners to develop treatment plans that will ensure positive outcomes for the patient Psychopathology And Diagnostic Reasoning Assignment Discussion.

Subjective:

CC (chief complaint): CL, an 18 year old patient states that she came to the clinic for her depression, irritability, aggression and impulsivity. The patient has been trying to manage her depression since the age of nine.

HPI: The patient was diagnosed with depression at the age of nine. She has history of treatment since age 9 for conduct disorder, depression, history of taking citalopram which worsened her irritability, aggression, impulsivity. She has been in a 90-day teen residential mental health facility discharged three months ago with lithium 300mg in am and 600mg at bedtime, aripiprazole 2.5mg in the morning. She has a history of domestic violence toward her older brother.

Past Psychiatric History:

• General Statement: The patient was diagnosed with depression at the age of 9.
• Caregivers (if applicable): The patient lives with her parents and grandmother from whom she is reported to have been stealing money to buy shoes, purses and clothes among other things.
• Hospitalizations: The patient has been in a 90-day teen residential mental health facility discharged three months ago.
• Medication trials: CL has prescriptions for lithium 300mg in the morning and 600mg at bedtime, aripiprazole 2.5mg in the morning.
• Psychotherapy or Previous Psychiatric Diagnosis: CL was diagnosed with depression at the age of 9 and experiences irritation, impulsivity and aggression Psychopathology And Diagnostic Reasoning Assignment Discussion.

Substance Current Use and History: CL tested positive for marijuana use before being admitted to the 90-day teen residential mental health facility and is believed to be hiding her medication by her parents.

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Family Psychiatric/Substance Use History: The patient’s grandmother has a history of bipolar disorder while her maternal aunt and her biological mother have anxiety.

Psychosocial History: The patient reports that her appetite is ravishing. While she is not currently partnered, she reports she is bisexual and that lately, she is hyper-sexual reporting an increase of unprotected sex. She has a Nexplanon implant. The patient has history of self-harm with cutting but reports having last engaged in the behavior 6 months ago.

Medical History:

• Current Medications: The patient is on with lithium 300mg in am and 600mg at bedtime, aripiprazole 2.5mg in the morning.
• Allergies: CL reports no recorded allergies.

• Reproductive Hx: She has a Nexplanon implant and reports and increase in unprotected sex. Psychopathology And Diagnostic Reasoning Assignment Discussion

ROS:

• General: No fevers, No chills. No significant unintentional weight change, No change in exercise tolerance.
• Head: No headaches, No dizziness.
• Eyes: No acute vision changes/photophobia during HA, No eye pain, No redness, No and discharge.
• Ears: No change in hearing, No ear pain, No ear drainage.
• Nose: No epistaxis, No congestion.
• Mouth: No sore throat, No difficulty swallowing.
• Neck: No stiffness, No pain, No noted masses.
• Chest: No dyspnea, No wheezing.
• Skin: Patient with No complaints of rashes or lesions.
• Cardiovascular: No chest pains, No palpitations.
• Gastrointestinal: No change in appetite, No abdominal pains, No bowel habit changes, No emesis.
• Genitourinary: No urinary urgency, No dysuria, No change in nature of urine.
• Musculoskeletal: No pain in muscles or joints, No paresthesias or numbness.
• Neurologic: No weakness. No changes in sensation.
• Psychiatric: Experiences depressive symptoms, significant changes in sleep habits (only sleeps for 2 to 3 hours), Patient experiences thought of hurting self and others.

Assessment: Psychopathology And Diagnostic Reasoning Assignment Discussion

Mental Status Examination:

• Appearance/behavior: The patient appeared energetic and hyperactive during her assessment.
• Speech/language: The patient’s speech was pressured and therefore difficult to interrupt. She was also emphatic and loud.
• Mood/Affect: The patient was expansive. She also displayed a low tolerance for frustration.
• Thought Process: The patient displayed a fight of ideas often shifting from topic to topic after a continuous flow of accelerated speech.
• Perpetual Disturbances: Patient displayed some paranoid features.

Differential Diagnoses:

• Major Depressive disorder
• Bipolar Disorder
• Borderline Personality Disorder

Reflections:

The patient appears to be suffering from bipolar disorder. This conclusion is supported by not only her symptoms but the fact that her grandmother was diagnosed with the same. Bipolar disorder is a relatively common psychiatric disorder that is characterized by cognitive deficits and affective instability especially when a person is going through mood episodes. According to Masso Rodriguez, et al., (2021), one of the main differences between people with bipolar disorder and those with borderline personality disorder is that the former will tend to experience both depression and mania while the latter experience feelings of desperation, emptiness, anger, loneliness, hopelessness and also intense emotional pain Psychopathology And Diagnostic Reasoning Assignment Discussion.

References

Masso Rodriguez, A., Hogg, B., Gardoki-Souto, I., Valiente-Gómez, A., Trabsa, A., Mosquera, D., … & Amann, B. L. (2021). Clinical Features, Neuropsychology and Neuroimaging in Bipolar and Borderline Personality Disorder: A Systematic Review of Cross-Diagnostic Studies. Frontiers in psychiatry, 12, 895.

Assignment: Assessing and Diagnosing Patients With Mood Disorders

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Accurately diagnosing depressive disorders can be challenging given their periodic and, at times, cyclic nature. Some of these disorders occur in response to stressors and, depending on the cultural history of the client, may affect their decision to seek treatment. Bipolar disorders can also be difficult to properly diagnose. While clients with a bipolar or related disorder will likely have to contend with the disorder indefinitely, many find that the use of medication and evidence-based treatments have favorable outcomes.

To Prepare: Psychopathology And Diagnostic Reasoning Assignment Discussion

• Review this week’s Learning Resources. Consider the insights they provide about assessing and diagnosing mood disorders.
• Download the Comprehensive Psychiatric Evaluation Template, which you will use to complete this Assignment. Also review the Comprehensive Psychiatric Evaluation Exemplar to see an example of a completed evaluation document.
• By Day 1 of this week, select a specific video case study to use for this Assignment from the Video Case Selections choices in the Learning Resources. View your assigned video case and review the additional data for the case in the “Case History Reports” document, keeping the requirements of the evaluation template in mind.
• Consider what history would be necessary to collect from this patient.
• Consider what interview questions you would need to ask this patient.
• Identify at least three possible differential diagnoses for the patient. Psychiatric & Medical Diagnoses

By Day 7 of Week 3

Complete and submit your Comprehensive Psychiatric Evaluation, including your differential diagnosis and critical-thinking process to formulate a primary diagnosis. Incorporate the following into your responses in the template: Psychopathology And Diagnostic Reasoning Assignment Discussion

• 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 the patient’s mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses with supporting evidence, listed in order from highest priority to lowest priority. Compare the DSM-5-TR 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.
• Reflection notes: What would you do differently with this client if you could conduct the session over? 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.)Psychopathology And Diagnostic Reasoning Assignment Discussion.

Further questions to answer: How you would you approach your assessment? Would you ask to include family members for collateral information? What tests or assessments would you order or conduct? Are there any referrals from which your patient could benefit? How would you promote overall health and disease prevention?

Resources

Sadock, B. J., Sadock, V. A., and Ruiz, P. (2015). Kaplan & Sadock’s synopsis of psychiatry (11th ed.). Wolters Kluwer.

• Chapter 9, Anxiety Disorders
• Chapter 10, Obsessive-Compulsive and Related Disorders
• Chapter 11, Trauma- and Stressor-Related Disorders
• Chapter 31.11 Trauma-Stressor Related Disorders in Children
• Chapter 31.13 Anxiety Disorders in Infancy, Childhood, and Adolescence
• Chapter 31.14 Obsessive-Compulsive Disorder in Childhood and Adolescence Psychopathology And Diagnostic Reasoning Assignment Discussion

Case Study

Name: Ms. Cheyenne Lisenbe

Gender: female

Age:18 years old

T- 97.4 P- 94 R 22 136/86 Ht 5’2 Wt 121

Background: Currently living with her parents in Locust Grove, Oklahoma along with two

younger sisters and 1 older brother. She is a senior in high school, not currently partnered,

reports she is bisexual, lately hyper-sexual reporting increase of unprotected sex. She has been

stealing money out of her grandmother’s purse to buy clothes, shoes, purses, “and just other

things. She has history of treatment since age 9 for conduct disorder, depression, history of

taking citalopram which worsened her irritability, aggression, impulsivity. She has been in a 90-

day teen residential mental health facility discharged three months ago with lithium 300mg in am

and 600mg at bedtime, aripiprazole 2.5mg in the morning. When discharged, her labs were Psychopathology And Diagnostic Reasoning Assignment Discussion

within normal ranges and urine toxicology negative. She was positive for cannabis upon

admission. Her parents believe she is hiding her medication as she has made comments “they

slow me down; they make me not think fast” She has hx of domestic violence toward her older

brother with juvenile assault charge. No current legal issues. Her grandmother has hx of bipolar

disorder; her mother and her maternal aunt have anxiety. She is sleeping 2-3hrs/24 hrs. Reports

her appetite “ravishing.” She has no medical issues; has Nexplanon implant; hx of self-harm with

cutting, last engaged in the behavior 6 months ago.

Symptom Media. (Producer). (2018). Training title 150 [Video]. https://video-alexanderstreetcom.ezp.waldenulibrary.org/watch/training-title-150  Psychopathology And Diagnostic Reasoning Assignment Discussion

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Instructions

Fill out the attached template in its entirety using the case study and video for more information. See RUBRIC attached as well as exemplar template. Complete all the tabs in the review of systems on the template. Use 4 pages to complete this template. Provide at least references dated within the last 5 years APA 7^th edition format. Give an introduction, purpose, and conclusion Psychopathology And Diagnostic Reasoning Assignment Discussion