Subjective

The patient who has been selected to be part of this examination is a 25-year-old female who has come with the chief complaint of depression. The other symptoms that have been presented by Sarah include cases of a reduction in her concentration, she has gained weight, she has had an increase in appetite, she has had a rise in cases of being sad, always exhausted, and low interest in activities she loved in the past, and that she is overwhelmed by activities. The patient has reported that she has had an increase in the cases of sleep whereby the patient sleeps for between 10 and 12 hours each night and that she has a nap during the day and always has slept all through the weekend. On the social aspect of the patient, it is presented that she is working in the pediatrician’s office as a receptionist. The reason for coming is as well attributed to the push by her boss due to the increase in the number of mistakes that she has been making in the recent past. She has come because she could not wish to lose her job since she was given the option of either seeing the doctor or she was going to be let go. The patient has reported that she has had an increase in her weight and that over the last few months she has had an addition of 10 pounds. The symptoms that are presented by the patient include cases of suicidal ideation, low intent, and paranoia, and this is seen from the view of the other staff in the office towards her. The patient has denied having any mental health diagnosis and that she received a surgical procedure when she was 13 years old when she had an appendectomy. The medication that she is using at the moment is only vitamins and birth control medication. There has not been a presentation of any allergic reactions that she could have.

On social history, Sarah O’neil has indicated that she is married but she points out that she has not had children and that she is having a stressful relationship at the moment in her marriage. She is learned and has and has an associate degree and she is still going to school. She points out that she goes to school parties and goes to work but this has affected her grades. The patient takes alcohol and she points out that she takes a moderate quantity of alcohol. She has posited that she does not take any drugs and she has not taken any drugs.

On family, the patient has pointed out that she had a challenging childhood. Her father is alive but is recovering from excessive use of alcohol while her mother committed suicide when she was 48 years old and she was suffering from schizophrenia. She has one sibling, a sister who has been diagnosed with depression.

Include chief complaint, subjective information from the patient, names and relations of others present in the interview, and basic demographic information of the patient. HPI, Past Medical and Psychiatric History, Social History.

Objective                

The vital signs of the patient are recorded to be Temperature=98.9, Pulse=68, Blood pressure=110/76 Respiration= 18, SpO2 =97% room air.  Height 5’ 3” inches Weight 175 lbs. BMI 31.0

On the examination of the skin, hair, and nails of the patient, it is found that there is no indication of any issues of rashes and that there is no indication of any changes in the hair texture and there is no indication of the patient having any indication of traumatic experience. The patient having a neck examination shows that she does not have any issues of thyromegaly and there is no indication of an enlargement of the thyroid glands.

The patient has denied having any pain in the abdomen and does not have any indication of tenderness. There is no indication of the patient being guarded at the touch of her stomach. The patient does not indicate any palpability of the spleen. On the examination of the neurological functioning, it is found that the patient has a score of 30/30. There is no indication of any sensory changes as there is a lack of enough commitment on the muscle and that range of having an equal bilateral basis.

The patient has been exposed to various tests that could help in the process of determination of the diagnosis. The first one is the complete blood count which is found to be within normal range. The comprehensive metabolic panel is found to be within the normal range and the thyroid stimulating hormone is carried out and is within the normal range. The blood alcohol level and the urine toxicology are as well found to be negative.

The mental examination of the patient shows that she has a slow speech and the speech is as well found to be monotonous. There is as well an indication that the mood of the patient is depressed and that she has a mild postural tremor. When she is being examined, it is found that she is always fidgeting with her hands and her legs. About the effects, it is found that the patient is anxious and that the thinking of the patient shows that she has a suicidal ideation but does not have an intention. She is as well found to have paranoid ideation. The patient can think logically and linearly and she is with poor judgment. The patient as well is possessing fair cognition. 

This is where the “facts” are located. Include relevant labs, test results, vitals, and Review of Systems (ROS) – if ROS is negative, “ROS noncontributory,” or “ROS negative except…” Include MSE, risk assessment here, and psychiatric screening measure results.

Assessment

(F34.1). Persistent Depressive Disorder

This is a mental health condition that results in a person having a persistent urge of doing one thing over and over. The patient has come to the health setting with a complaint of depression. The symptoms that have been presented by the patient include issues of reduction in appetite and cases of loss in concentration as well as the issues of fatigue which are in line with symptoms that are presented by patients who are suffering from the persistent depressive disorder as alluded to by Patel and Rose (2021).

(F 33.3) Major Depressive Disorder

This is a mental health condition as alluded to by Mullen (2018) that is featured by a persistent issue of the depressive mood a person. The patient with this condition as well experiences issues of loss of interest in activities and that one may end up lacking any interest to the end that their day-to-day activities are affected. The process of diagnosis of this condition is carried out by the examination of the symptoms that are presented by the patient. The symptoms that have been presented by Sarah and that are in line with the issue of the major depressive disorder include a rise in sleep as she sleeps for 10-12 hours and still naps during the day, loss of interest, concentration reduction of the patient, change in behavior of the patient, and the cases of having suicidal thoughts. The patient as well as presented that she has had issues of being discontented and that one is faced with issues of guilt and lack of hope.

(F34.0) Cyclothymic disorder

 

This is a mental health condition that results in the patient having emotional highs and lows. The patient suffering from this condition as alluded to by Bielecki and Gupta (2021) has symptoms such as intermittent psychological highs and lows that become worse with time. The patient with this condition will therefore show issues of irritation and will experience issues of change in moods or mood swings. The patient has reported that she has had a rise in the amount of sleep that she is sleeping and that she has had a rise in weight. The patient as well may end up indicating an excessive amount of energy.

Include your findings, diagnosis, and differentials (DSM-5 and any other medical diagnosis) along with ICD-10 codes, treatment options, and patient input regarding treatment options (if possible), including obstacles to treatment.

Plan

The goal of treating Sarah is to ensure that she will be in a position to take part in an extracurricular activity such as a sporting activity and that she is supposed to get closer help on mental health examination and regular talk regarding the suicidal ideation. The intervention that is intended to be applied will be to ensure the symptoms that are presented by the patient are eliminated. The proposed medication that is supposed to be implemented is the use of Lexapro 5mg PO daily. This is used because an SSRI will help in the control of the panic and depressive thoughts of the patient. The patient as well is supposed to get cognitive behavioral therapy that could help her change her thoughts and ensure that she can have positive thoughts.

The patient is supposed to be thought effective ways of management of her thoughts. The patient should be able to handle the way she thinks. There will be a need for the patient to have a follow-up after 4 weeks.

 

                        

Include a specific plan, including medications & dosing & titration considerations, lab work ordered, referrals to psychiatric and medical providers, therapy recommendations, holistic options, and complementary therapies, and rationale for your decisions. Include when you will want to see the patient next. This comprehensive plan should relate directly to your Assessment.

References

Bielecki, J. E., & Gupta, V. (2021). Cyclothymic Disorder. In StatPearls [Internet]. StatPearls Publishing.

Mullen, S. (2018). Major depressive disorder in children and adolescents. Mental Health Clinician8(6), 275-283.

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

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