Week 7_Case study # 3

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WEEK # 7 _ COMPLEX CASE STUDY PRESENTATION

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INSTRUCTIONS

Answer the questions presented in the discussion (case presentation), supporting your rationale with at least two scholarly references from the literature for each question.


CASE PRESENTATION


Questions

1. What treatments would you recommend for this patient to be a part of?

2. What information would be important to gather from the assessment?

Subjective:
CC (chief complaint): “For the past couple of weeks, I’ve just been feeling super down. I haven’t been able to do the normal activities that I love to do like read my books or even film makeup tutorials on tiktok. I’ve honestly been staying up most of the nights and its because I cannot sleep. If I am being honest. I know that this is stupid, but I was struggling with managing my emotions after I got dumped by my boyfriend of 2 years. We had worked through alot of our problems so for him to just leave me, it really hurt. I feel an intense amount of guilt like its my fault. It was after I disclosed some of my trauma to him. Maybe it was too much for him but what about what I’ve experienced. Before I went to the hospital I’d been thinking about death
alot. Like what would happen if I wasn’t here anymore. Thats why I made the decision to go to the hospital.”

HPI: C.H is a 17-year-old, African American female brought in for a psychiatric evaluation after being discharged from a psychiatric hospital due to depressive symptoms. Patient presents with cohesive and organized thought. Patient reports that they have been experiencing depressive symptoms for the past couple of weeks. Patient discloses the symptoms that they have been experiencing. Patient reports recently experiencing a breakup. Patient disclosed not being able to engage in their typical activities that they usually engage in. Patient expressed their inability to
manage and regulate their emotions. Patient reported often feeling down. Patient expressed the feelings of guilt and taking believed ownership of being the root cause of their relationship ending due to their expressing their trauma. Patient discussed making the decision to go to the hospital as they discussed how they recognized how their emotional well being was in danger. Patient discussed desiring to get the right help and being open to medication. Substance Use History: Patient reports engagement of alcohol. Patients described themselves as a social drinker. Patient is under the legal age and cannot purchase their own alcoholic beverages. Patient disclosed that if she goes to a party they will engage in drinking but not often.
Patient disclosed the last time they engaged in drinking was four months ago. Patients reported that they don’t believe their engagement in drinking was problematic. Patient was educated on the dangers of underage drinking and how important it is to not drink and drive. Patient denied usage of the other substances.

Medical History:
◦ Current Medications: Patient denies taking medication. Patient did report previously
that they were on birth control four months ago but decided to not engage in taking birth control.
◦ Allergies: Patient does not have any known allergies at this present time. ◦
Reproductive Hx: Patient reports that their period flow is timely. Patient reports they have never been pregnant.

ROS:
◦ GENERAL: Patient reports that she has lost some weight as a result of not eating.
◦ HEENT: Patient reports no abnormalities or concerns with their eyes.
◦ SKIN: Patient has not disclosed any abnormalities with their skin.
◦ CARDIOVASCULAR: Patient reports that she does feel really anxious which leads to what she describes as a anxiety attack.
◦ RESPIRATORY: Patient denies having trouble with breathing.
◦ GASTROINTESTINAL: Patient does not report any discomfort in their abdominal region.
◦ GENITOURINARY: Patient did not disclose any concerns.
◦ NEUROLOGICAL: Patient does not discuss any abnormalities with their spine,
reflexes, eyes, and head .
◦ MUSCULOSKELETAL: Patient did not disclose any abnormalities with muscles.
◦ HEMATOLOGIC: Patient denies bruising.
◦ LYMPHATICS: Patient does not report any difficulties with their lymphatic system.
◦ ENDOCRINOLOGIC: Patient does not report any concerns within their endocrinology system.

Objective:
Physical exam:
Vital Signs: B.P.: 113/74, Pulse:96, RR: 20, non-labored, Temp: 97, BMI: 21.1
General: Patient is oriented x4. Patient is well groomed and properly dressed. Patient was not
observed to not be in any acute distress. Patient denies suicidal ideations.
HEENT: Patient was not observed to have any concerns involving their head.
Chest/Lungs: Patient lungs were clear as evidenced by the assessment.

Heart/Peripheral Vascular: Patient was observed to not have any abnormalities.
Gastrointestinal: Patient does not disclose concerns within their gastrointestinals.
Genital/Rectal: Patient does not disclose concerns with their genitals or rectal region.
Endocrinologic: Patient blood sugar was 115.
Skin: No tenting was observed.
Lymphatics: Patient lymphatics were within normal ranges.

Diagnostic results:
◦ In order to assess the patient, specific assessments were used. The Patient Health
Questionnaire also known as the PHQ-9 was utilized to assess depression. Patient scored relatively high on the PHQ-9. The GAD-7, which is the Generalized Anxiety Assessment, was utilized to determine the level of anxiety the patient has. Patient scored moderately for anxiety.
The C-SSRS which is also known as the Columbia-Sucidie Severity Rating Scale which assess for suicide. Patient scored low for a suicide risk as client is currently denying being suicidal.

Assessment:
Mental Status Examination:
Patient is a 17-year old African American female minor who came in for a psychiatric
assessment after being discharged from a psychiatric hospital. Patient was oriented x4. Patient was appropriately dressed for the assessment. Patient was well-groomed and cooperative during the assessment. Patient thought content is cohesive and organized. Patient thought process was observed to be delayed. Patient presents with a dysphoric mood with a congruent affect. Patient was observed to have slow and low toned speech. Patient denies auditory and visual hallucinations. Patient denies homicidal ideations. Patient denies suicidal ideations. Patient did report that they went into the hospital a week ago due to thoughts of wanting to harm themselves. Patients reported not having a plan to harm themselves.

Differential Diagnoses:

1 Manic Episodes with Irritable Mood – Patients who are experiencing manic
episodes with irritable moods could potentially exhibit symptoms that align with major depressive disorder. One of the main disconnects of this diagnosis is the main fact being that the symptoms the patient is expressing is not an episode, it is however a consistent daily experience.

2 Substance/Medication-Induced Depressive or Bipolar Disorder – This diagnosis can be eliminated as the patient is not taking any substances at the current moment. However, medications or even substances can have detrimental impact on an individual’s body chemistry which can lead to a depressive or bipolar diagnosis.

3 Adjustment Disorder with Depressed Mood- This diagnosis is a close diagnosis to what is occuring with the patient. Patient disclosed a recent break up with their partner. Patient is obviously going through an adjustment time period. However, the patient previously disclosed during the assessment that she has been experiencing depressive periods for a while and admits to having trauma that has not been addressed. This would rule out the Adjustment Disorder as a diagnosis.

The primary diagnosis for the patient is F296.33 Major Depressive Disorder. Usually when an individual is diagnosed with this diagnosis. One of the requirements for this diagnosis is for the individual to experience the symptoms on a daily basis. Individuals who maybe diagnosed with MDD, may not always show up as an individual who is depressed. Being able to evaluate a patient based off the symptoms that they present will be equally as important. There isn’t one root cause of Major Depressive Disorder. Many different factors may come into play when it comes to diagnosing an individual with MDD. Its critical to assess for suicide as well.
Individuals with MDD may more than likely struggle with suicide ideation on a higher level. Ensuring the safety and overall being of patients who have this diagnosis could look like creating a safety plan. A safety plan holds the patient and other individuals involved accountable for their actions during times of intense emotions. Patients will be encouraged to utilize coping skills and engage in activities that keeps them grounded and occupied. They will be reminded of their life’s purpose and the people that make them feel safe. Furthermore, its incredibly important for individuals who are diagnosed with MDD to feel supported, heard and given a safe space to
exercise their beliefs.

Reflections:
During this assessment, many key elements were made. Patient is experiencing extreme levels of depression, history of suicidal ideation, reliving traumas, and recent break up with partner. Patient denies history of past mental health diagnosis but reports self-diagnosing themselves with major depression disorder. Patient is experiencing a lot of different changes in their life. In order for them to be able to live a productive life. They need to be able to have the support they need around them. Most patients who discharge from the hospital are connected with medical
providers such as a psychiatrist, psychiatric nurse practitioner, and/or therapist. As a medical provider, patients’ symptoms are concerning. Patient previously reported the loss of some weight. Patient expressed difficulty with falling sleep, and even not being interested in their typical activities. Patient needs to feel supported during their treatment process. It would be in the patients best interest to have a well rounded team for their treatment.

Case Formulation and Treatment Plan
1. Psychotherapy – Based upon the assessment. The best form of therapy for patients would include EMDR and DBT therapy. EMDR is also known as Eye Movement Desensitization and Reprocessing therapy. EMDR is often utilized for individuals who have severe trauma theyhave not processed as of yet. Patient has experienced intense trauma and with this knowledge, it is believed it could be a good form of therapy for the patient.

DBT, also known as Dialectal Behavior Therapy utilizes key points such as mindfulness, interpersonal effectiveness, emotion regulation, and even distress tolerance. Patient reports struggling with regulating their emotions.
Patient recently experienced a break up and learning tools on how to manage their stress as well as working on relationships with individuals outside of themselves could be extremely beneficial for the patient. I also believe the development of a safety plan should be created with patients and given to patients to utilize in difficult intense emotions.

2. Pharmacology -Fluoxetine Hcl 20mg in capsule form. Fluoxetine is an antidepressant that also treats other diagnoses such as panic disorders. Patient reported that they are willing to engage in taking prescribed medications. Patients were instructed to contact medical providers if they were determined to have difficulty or adverse reactions.

3. Health Promotion – Patients should be encouraged to engage in activities such as
yoga and acupuncture which is known to have a great successful impact on individuals who struggle with trauma.
4. Patient Education – Patient could utilize education surrounding the medication they
are being prescribed. Patient could also utilize education surrounding coping skills they can use to manage their emotions, in which patients previously expressed difficulty with balancing their emotions.
5. Social Determinant of Health – Patient should be aware of how their relationships with others may impact how they feel about themselves. Patients ability to access medical providers such as a therapist should also be considered when referring them to a provider.

References:
Trivedi M. H. (2020). Major Depressive Disorder in Primary Care: Strategies for
Identification. The Journal of clinical psychiatry, 81(2), UT17042BR1C.
Teusen, C., Hapfelmeier, A., von Schrottenberg, V., Gökce, F., Pitschel-Walz, G., Henningsen,
P., Gensichen, J., Schneider, A., & POKAL-Study-Group (2022). Combining the GP’s
assessment and the PHQ-9 questionnaire leads to more reliable and clinically relevant diagnoses
in primary care. PloS one, 17(10), e0276534.
Harmer, B., Lee, S., Duong, T. V. H., & Saadabadi, A. (2022). Suicidal Ideation. In
StatPearls. StatPearls Publishing.

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