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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 their 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-TR diagnostic criteria and is supported by the patient’s symptoms.

Plan: What was your plan for psychotherapy (include one health promotion activity and patient education)? What was your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan. Discuss an identified social determinant of health impacting this patient’s mental health status and provide your recommendation for a referral to assist this patient in meeting this identified need (students will need to conduct research on this topic both in the literature and for community resources). 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.

Sample Paper For Above instruction

Introduction

The assessment of a patient's mental health requires a comprehensive approach that integrates subjective reports, objective observations, a thorough mental status examination, diagnostic reasoning, and a detailed plan for intervention. This case analysis exemplifies the psychiatric evaluation process, highlighting critical elements such as symptom history, differential diagnosis formulation, and personalized treatment strategies, including social determinants of health and follow-up considerations.

Subjective Data Collection

The patient reported experiencing persistent feelings of sadness, loss of interest in activities, and episodes of fatigue over the past six weeks. They described these symptoms as moderate to severe, significantly impairing their ability to perform daily tasks and maintain social relationships. The patient indicated that their mood fluctuations have affected their concentration and motivation, impacting both their occupational performance and interpersonal interactions. The symptom duration of over a month and the progressive nature suggest a potential depressive disorder, warranting further assessment.

Objective Findings During Psychiatric Assessment

During the psychiatric evaluation, observable indicators included a depressed affect, decreased psychomotor activity, and limited eye contact. The patient's speech was slow, and their posture appeared drooped, reflecting emotional distress. Cognitive functions such as attention and memory appeared mildly impaired, aligning with reported concentration difficulties. No overt psychotic features or suicidal ideation were evident during the assessment, but the patient's insight into their condition was partial.

Mental Status Examination

The mental status exam revealed a disheveled appearance, a flat affect, and diminished psychomotor activity. Their orientation was intact, but thought processes appeared slowed. The patient expressed feelings of worthlessness and hopelessness but denied current suicidal ideation. Judgement appeared intact, but insight was limited. These findings collectively support a diagnosis consistent with major depressive disorder.

Differential Diagnoses

1. Major Depressive Disorder (Primary Diagnosis): The patient's core symptoms—persistent low mood, anhedonia, fatigue, and impaired functioning—align with DSM-5-TR criteria for MDD, making it the primary diagnosis.
2. Anxiety Disorder: The patient's concentration difficulties and worry may also suggest comorbid generalized anxiety disorder, common in depressive presentations.
3. Hypothyroidism: Fatigue and low mood could be symptoms of hypothyroidism; thus, a labs assessment is recommended to rule it out.

The primary diagnosis of major depression is prioritized based on symptom severity, duration, and functional impact, fulfilling DSM-5-TR criteria.

Treatment and Management Plan

The therapeutic plan includes initiating cognitive-behavioral therapy (CBT) aimed at addressing negative thought patterns and behavioral activation. As part of health promotion, patient education on maintaining a routine, sleep hygiene, and physical activity was emphasized.

Pharmacologic treatment involves starting an SSRI, such as sertraline, given its efficacy and tolerability profile for depression. Nonpharmacologic interventions encompass lifestyle modifications, mindfulness exercises, and social support engagement. Alternative therapies, like acupuncture, may be considered adjunctively.

Follow-up will be scheduled at four-week intervals to monitor medication effectiveness, side effects, and progression of symptoms. The rationale for this integrated approach aligns with evidence supporting combined psychotherapy and pharmacotherapy for moderate to severe depression.

An important social determinant influencing this patient is social isolation, which exacerbates depressive symptoms. A referral to community support groups and social services is recommended to address social needs and foster connectedness.

Reflection and Future Interventions

If conducting the session again, I would incorporate a more thorough exploration of the patient's support network early in the assessment to tailor social interventions more effectively. To improve engagement, I would also employ motivational interviewing techniques to enhance treatment adherence.

Follow-up outcomes would be evaluated based on symptom reduction, functional improvement, and patient satisfaction. If the initial intervention was unsuccessful, adjustments such as medication change or more intensive therapy could be considered.

Conclusion

This case underscores the importance of a holistic, patient-centered approach in psychiatric care. By integrating subjective reports, objective observations, diagnostic criteria, and social factors, clinicians can develop comprehensive treatment plans that improve mental health outcomes for their patients.

References

• American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).
• Cuijpers, P., et al. (2016). The efficacy of psychotherapy and pharmacotherapy in treating depression: A meta-analysis. Journal of Affective Disorders, 202, 145-155.
• Kendall, P. C., & Hedtke, K. A. (2006). Cognitive-behavioral therapy for adolescent depression. Journal of Clinical Psychology, 62(5), 545-558.
• National Institute of Mental Health. (2020). Major Depression. Retrieved from https://www.nimh.nih.gov/health/statistics/major-depression
• Otte, C., et al. (2016). Major depressive disorder. Nature Reviews Disease Primers, 2, 16065.
• Williams, J. M. G., & Cuijpers, P. (2015). From neuron to neighborhood: The neuroscience of psychotherapy outcome. American Psychologist, 70(1), 40-52.
• World Health Organization. (2017). Depression and other common mental disorders: Global health estimates.
• Zimmerman, M., et al. (2014). The clinical utility of diagnosing depression with DSM-5 criteria. Journal of Clinical Psychiatry, 75(1), 66-72.
• McCabe, R., & Davis, M. (2015). Social determinants of mental health. Journal of Public Mental Health, 14(3), 109-114.
• Markowitz, J. C., & Weissman, M. M. (2012). Treatment of depression and social isolation: The role of social support. Journal of Affective Disorders, 137(1-3), 152-158.