Psychiatric Evaluation: Sadness and Anxiety

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Table of Contents

Past Psychiatric History
Substance Current Use and History
Family Psychiatric/Substance Use History
Psychosocial History
Medical History
Physical exam
References

CC (chief complaint): The patient is being evaluated for severe sadness and anxiety. For the past four months, she has suffered from depression, lethargy, insomnia, decreased appetite, anxiety, and poor focus. She has previously thought of and tried suicide but has been unsuccessful.
HPI: M.S is a 30-year-old American woman brought into this facility for psychiatric evaluation for severe sadness and anxiety. Her PCP referred her for this evaluation and treatment.

Past Psychiatric History

General Statement: At the age of 20, when her parents were going through a divorce, the woman sought help for her sadness. Due to these sessions, she started visiting a therapist weekly and was given medicine for her depression. She kept up with her counseling sessions and remained on the medication prescribed for her depression well into her early twenties. She started consuming alcohol when she was 26 and eventually sought detoxification treatment.
Hospitalizations: The patient has had three separate hospitalizations throughout her life. The most recent time she was admitted to the hospital was in September 2016. She has completed one residential treatment program in addition to two detoxification programs. The final residential treatment program occurred in August 2016, and the last detoxification program occurred in July 2016. She has a history of suicidal ideation, but she does not have an account of any real attempts at suicide or actions that involve self-harm.
Medication trials: The patient in the past has attempted treatment with haloperidol, which resulted in a dystonic reaction; risperidone, which caused hyperprolactinemia; and olanzapine, which was effective; however, her insurance company refused to pay for it.
Psychotherapy or Previous Psychiatric Diagnosis: The patient is an American woman who is 30 years old and has been attending therapy for quite some time. Both anxiety and depression have been identified as being present in her life. She believes that therapy has helped her better understand her feelings and thoughts, making it easier for her to manage her symptoms (Kirsh et al., 2019). She has found the cure to be beneficial in controlling her symptoms.

Substance Current Use and History

Caffeine, nicotine, and alcohol have all been used by women in the past. She utilizes these substances daily, and her most recent use was today. She employs them by inhaling and snorting them. She has a history of tremors, Delirium Tremens, and seizures resulting from withdrawal.

Family Psychiatric/Substance Use History

The woman’s mother was treated for depression and anxiety with medication and counseling. Her father was a heavy drinker who died of liver illness. When the woman was 19, her sister committed suicide. There is no history of mental illness or substance misuse in the woman.

Psychosocial History

The patient’s US-born parents raised her and the patient has two brothers. Her husband and two children are her immediate family. Her husband is a doctor and she has a bachelor’s degree in psychology. The patient enjoys reading, cooking, and spending time with family. Violence or trauma were not in the patient’s medical history.

Medical History

The patient is a 30-year-old American lady with seizures and head trauma. She also underwent surgery to fix a deviated septum.

Current Medications: The woman has been using oral contraception for the past five years. She’s been taking them to avoid becoming pregnant. Every day, she takes one medication.
Allergies: The woman has a history of drug, food, and environmental sensitivities. Angioedema, anaphylaxis, and other allergic responses have occurred in her.
Reproductive Hx: The American lady has a history of menstruation. She is neither pregnant nor is she breastfeeding or lactating. She does not use contraception and has no sexual issues.
ROS:
- GENERAL: The patient is a 30-year-old female American.
- HEENT: The patient reports hazy vision and eye pain.
- SKIN: The patient complains of a rash.
- CARDIOVASCULAR: The patient complains of chest discomfort and palpitations.
- RESPIRATORY: The patient complains about the shortness of breath and trouble breathing.
- GASTROINTESTINAL: Complains of nausea and vomiting.
- GENITOURINARY: Mentions pelvic pain.
- 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.

Physical exam

Diagnostic results

She has been taking 20mg of Fluoxetine (Prozac) daily for the previous two weeks with no relief. The patient’s medical history includes depression, anxiety, and an eating issue. History of mental illness: The patient has a history of sadness and anxiety (Ran et al., 2019). She has been diagnosed with an eating disorder and has previously sought therapy for it. Medications: The patient takes Fluoxetine (Prozac) at 20mg daily. Allergies: The patient has no known allergies. Physical exam suggests slight distress. She’s attentive to the person, place, and situation. Normal head and neck. Her pinkish extremities have strong pulses. Her abdomen is pain-free and lump-free. Based on the patient’s history, physical exam, and mental health history, his sorrow and anxiety are likely worsening. Her medicine may be causing her current state.

Assessment

Mental Status Examination: The patient’s age seems accurate. She’ll take the test. The patient is clean, well-groomed, and dressed for the setting. The patient denies abnormal motor activity. Her volume and tone are appropriate. The patient’s thoughts are rational and goal-oriented. No data suggests concept flight or loose connection. Her affect is euthymic; hence her mood is euthymic. She grinned when appropriate. She denies having auditory or visual hallucinations. Delusions are unproven. She has no suicidal or homicidal ideas currently. She’s smart and savvy. Recent and distant memories are unaffected.

Differential Diagnoses: Major depressive disorder, generalized anxiety disorder, panic disorder. Acute depression, anxiety, and lack of interest rule out MDD. Generalized anxiety disorder is caused by the patient’s worries. Panic disorder involves anxiety and panic attacks.

Reflections

I agree with my preceptor’s patient diagnosis. The patient’s symptoms suggest depression and GAD. I think the patient needs antidepressant and anxiety-reducing drugs (Alessio et al., 2020). Counseling and therapy could help the patient with her despair and anxiety. This taught me to examine all factors while screening for mental health issues. Age, ethnicity, socioeconomic determinants of health, and other risk factors are considered. Consider the patient’s medical history and other factors that may be causing mental health issues.

References

D’Alessio L., Korman, G. P., Sarudiansky, M., Guelman, L. R., Scévola, L., Pastore, A.,… & Roldán, E. J. (2020). Reducing allostatic load in depression and anxiety disorders: physical activity and yoga practice as add-on therapies.Frontiers in Psychiatry, 11, 501.

Kirsh, B., Martin, L., Hultqvist, J., & Eklund, M. (2019). Occupational therapy interventions in mental health: A literature review in search of evidence. Occupational Therapy in Mental Health, 35(2), 109-156.

Ran, M. S., Weng, X., Liu, Y. J., Zhang, T. M., Yu, Y. H., Peng, M. M.,… & Xiang, M. Z. (2019). Changes in treatment status of patients with severe mental illness in rural China, 1994–2015. BJPsych open, 5(2). doi: 10.1192/bjo.2019.13