Discuss the mental status examination results

LEARNING RESOURCES

· Carlat, D. J. (2017). The psychiatric interview (4th ed.). Wolters Kluwer.

· Section II. The Psychiatric History (Chapters 14–18)

· Section III. Interviewing for Diagnosis: The Psychiatric Review of Symptoms (Chapters 23–24)

· Lorberg, B., Davico, C., Martsenkovskyi, D., & Vitiello, B. (2019). Principles in using psychotropic medication in children and adolescents. Links to an external site. In J. M. Rey & A. Martin (Eds) , IACAPAP e-textbook of child and adolescent mental health (2019 ed., pp. 1–25). International Association for Child and Adolescent Psychiatry and Allied Professions. https://iacapap.org/_Resources/Persistent/45bdffb25befc353c9f61988e82105029504ab85/A.7-Psychopharmacology-2019.1.pdf

THE ASSIGNMENT

Assessment:

· Discuss the 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:

· 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 because of this treatment session?

· Include one social determinant of health according to the Healthy People 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.

PATIENTS INFORMATION

S:16y/o female presents with chief complaint of depression and anxiety for Psychiatry initial evaluation. Patient dealing with daily symptoms. Patient is requesting medical management to aid with symptoms.

Hx of mental health: Depression, Eating Disorder

Prescription Hx: Sertraline (Zoloft)

Symptoms: Decreased pleasure, mood, Persistent sadness, poor sleep, fatigue, appetite change, self-pity, Withdrawal from others and loneliness

lack of concentration, and fidgety. Symptoms of anxiety present eg. anxiousness, or irritability

Triggers/stressors: unclear

Mood/Affect: Depressed/Dysphoric

Suicidality: None reported

Substance Use: None reported

O: Insight and Judgement: No evidence of being outside normal limits

Thought Process: No evidence of being outside normal limits

A: Depression, mild. Generalized anxiety, mild.

P: Will prescribe medication to aid with depression and anxiety symptoms. Prescribed Bupropion 150mg PO daily. Selection based on patient’s history of binge eating without purging. F/U 1 month, or sooner if needed.

ANSWERS

Based on the information provided, the mental status examination results suggest that the patient is experiencing symptoms of depression and anxiety. These symptoms may include decreased pleasure, mood changes, persistent sadness, poor sleep, fatigue, appetite changes, self-pity, withdrawal from others, loneliness, lack of concentration, and fidgetiness.

Possible differential diagnoses for the patient’s symptoms could include major depressive disorder, persistent depressive disorder, and generalized anxiety disorder. Major depressive disorder is a common and severe mental health disorder that is characterized by the presence of symptoms such as depressed mood, loss of interest or pleasure, and changes in appetite, sleep, and energy levels. Persistent depressive disorder, also known as dysthymia, is a chronic form of depression that is characterized by the presence of symptoms such as low mood and anhedonia for at least two years. Generalized anxiety disorder is a common and chronic disorder that is characterized by excessive and persistent worry and anxiety about a variety of events and situations.

Based on the information provided, the primary diagnosis for this patient would be major depressive disorder. This diagnosis is supported by the patient’s reported symptoms of persistent sadness, poor sleep, fatigue, appetite changes, self-pity, withdrawal from others, and loneliness. These symptoms align with the diagnostic criteria for major depressive disorder in the DSM-5, which includes the presence of five or more of these symptoms during the same two-week period.

The treatment plan for this patient could include a combination of medication and talk therapy. The medication chosen for this patient would be bupropion (Wellbutrin), which is an FDA-approved antidepressant that has been shown to be effective in treating major depressive disorder. The dose prescribed would be 150mg orally once daily. Alternative treatments for major depressive disorder could include other antidepressants such as selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs), as well as psychotherapy such as cognitive-behavioral therapy (CBT).

The rationale for choosing bupropion for this patient is based on the patient’s history of binge eating without purging, as well as the potential for weight gain with other antidepressants such as SSRIs. Bupropion has..

Discuss the mental status examination results

ANSWERS

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