Comprehensive Psychiatric Evaluation and Patient Case Presentation ESSAY

Assignment 2: Comprehensive Psychiatric Evaluation and Patient Case Presentation

Assessing patients’ moods

Subjective;

Cc; chief complaint; “I can’t stop crying. All the time.”

L.T. is indeed a 32-years African American woman who is seeking psychiatric help. Since the baby’s delivery two months ago, the patient has been in a melancholy mood virtually every day. She admits that dealing with a newborn baby is difficult for her, so the child’s nursing is stressful. The client testifies to sleeplessness, including difficulty sleeping after birth. She also alleges a poor appetite and dissatisfaction with her looks, body size or form, shame, and avoidance of talking to friends, mainly if the newborn is crying. She describes her disagreeable disposition by saying, “Things simply bother her.” She also says to be disinterested in activities like writing, which she enjoyed. Although the client confessed to having suicidal ideation, he did not act on them. She insists that she has never considered hurting the child. For the time being, no psychotropic medications are indicated for the client.

Psychiatric History

· General Statement: The client never had a mental health evaluation or treatment.

· Hospitalizations: the client was just hospitalized for regular childbirth.

· Psychotherapy or Prior Psychiatric Treatment Was never medicated for mental health conditions and therefore had no history of mental health diseases.

Current and Past Uses of the Substance: The patient stated that he did not drink or use drugs. Psychiatric/Substance Abuse History in Her Household: Her uncle committed suicide with the help of a GSW. Uncle had been a heroin addict.

Patient’s psychosocial history: she is currently in a relationship with two kids and resides with her spouse. She worked retail for five years before becoming a stay-at-home mum. She only has one sibling and was brought up with both mother and father in Omaha, Nebraska. She does have a physics bachelor. She worked as a researcher math teacher for five years when her child was born. 2 months ago, L.T’s first kid was born. The customer has no prior legal experience.

L.T.’s past medical history is hypertension.

Medications in Use: Labetalol (100 mg) for HTN; acknowledges accidentally leaving dosages.

Allergies: Codeine

Reproductive Hx: L.T delivered a few months ago and is still breastfeeding. She is presently contraceptive-free. The woman does not have any sexual interaction since the baby’s delivery. She asserts that she has no interest in sexual activity.

ROS: There is no loss of weight, cold, fever, or weariness in general

HEENT: No vision alterations, doubled vision, or hepatitis in the eyes. No modifications in vision, rhinorrhea, congestion, and sore throat inside the ears, throat nose.

Skin: The tint of the body has remained unchanged. There is no itching and rash.

Cardiovascular: There is no soreness or discomfort in the chest, no beats, and no edema.

There is no cough, dyspnea, or sputum production.

Gastrointestinal: There has been a decrease in appetite. L.T wants weight reduction after the baby is born. There is no anorexia, vomiting, or diarrhea. In the belly, there seems to be no pain.

Genitourinary: No burning, hesitation, or urgency when urinating. The color and texture of the pee remain unchanged.

Neurological: Seizure’s numbness, no headaches or tingling in the extremities, and paralysis are all symptoms of epilepsy.

Musculoskeletal:  L.T didn’t get any stiffness or soreness in her back.

Hematologic: Anemia or bleeding does not appear to be a problem.

Lymphatics: There was no splenectomy, and there were swollen nodes in the backdrop.

Endocrinologic: no sweating, fever, or chill intolerance reported. Polyuria and polydipsia were not present.

Objective:

Signs of life: “T-97.6, P-97, R-22, BP-149/98, Ht 5’3 Wt 245lb”

Not Applicable for a physical examination

diagnostic results are Not Applicable

Assessment:  Examining L. T’s Mental Health Status: The patient is dressed suitably for the occasion and the weather. She’s a beautiful person.  Vigilant and focused on an individual, a location, and a time. Her recollection appeared to have remained intact throughout the experience. She is polite, yet she seems to be aloof in the evaluation. Her words are apparent, and she uses low tones when speaking. Her disposition is gloomy. The effect has suffocated no hallucinations or delusions. Suicide or suicide attempt thoughts are reported. She has had visions of death, but she has not acted on them.

Differential Diagnosis (Differential Diagnosis)

Postpartum depression; postpartum disorder is a type of depression that begins four weeks after a baby is born and lasts for four weeks. Symptoms of insomnia include depressive moods, increased anxiety, weight fluctuations (Sadock et al., 2015). Numerous signs of major depression, such as diminished enjoyment in activities, are common among people with depressive symptoms, such as feelings of improper guilt or lack of sound, as well as feelings of worthlessness and death of endangering the child (Mullins, 2021). Given that, that’s the most frequent symptom. The patient meets the signs and clinical diagnosis for major depression. It began four weeks after the birth of the child. The patient is melancholy and often weeps every day. The client describes being unhappy and sobbing practically every day, as well as having trouble sleeping, a diminished appetite, feelings of guilt, low self-esteem and inadequacy, a disinterest in pleasure activities, and suicidal ideas without the need for a plan.

MDD is defined by a depressed mood and perhaps a lack of enjoyment in activities. Feelings of grief or anxiousness, a lack of interest or pleasure in actions, hypersomnia, losing weight, energy dissipation, feelings of helplessness or unworthiness, improper guilt, common suicidal thoughts or fatality, decreased energy, and difficulty concentrating or indecisiveness (Sadock et al., 2015). Although, L.T exhibits the majority of these signs.

A brief mood illness characterized by a low mood or symptoms of mild depression is postpartum blues. Signs of Depression include dysphoria, mood instability, tearfulness, weeping, insufficient sleep, irritability, and diminished focus (Sadock et al., 2015). According to Mullins (2021), 30 to 50 percent of people have the disorder. Mothers who have recently given birth must meet the diagnostic criteria of the ailment to be diagnosed. Arise within two weeks of childbirth and subside within 2-3 days after delivery. If the symptoms linger for a more extended period, The clinical diagnosis for primary depressive illness is met in less than two weeks (Sadock et al.,2015). Since the symptoms lasted longer than two weeks, that’s not the most common condition.

Reflections

I studied several psychological disorders that share the same symptoms based on the scenario given. In brief, I’ve learned about mental health illness, a depressed mood that develops 4-6 weeks just after the baby is born. Other mental illnesses I’ve heard of include severe depression and postpartum blues, both of which have symptoms comparable to those of postpartum depression. Examining aspects associated with stressors and anxiety and depression disorder catalysts is necessary to provide an accurate diagnosis. (Wolters Kluwer et al., 2015). Drug safety, especially in the case of a baby, is a regulatory factor to be considered during the patient’s care. When a breastfeeding woman decides to take medicine, she should consider the drug’s possible benefits and the risks to her child. While all drugs pass via the breastmilk, their degree varies (Frieder et al.,2019). Furthermore, because individuals with depressive symptoms have suicidal thoughts and injure the infant, it is critical to inquire about such ideas to identify whether they are delusional or obsessive behavior and assure the mother and baby’s safety.

References

Frieder, A., Fersh, M., Hainline, R., & Deligiannidis, K. M. (2019). Pharmacotherapy of postpartum depression: current approaches and novel drug development. CNS drugs, 33(3), 265-282.

Mullins IV, C. H. (2021). Postpartum Blues. Patient Education and Counseling.

Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan & Sadock’s synopsis of psychiatry (11th ed.).

Wolters Kluwer. Sherman, L. J., & Ali, M. M. (2018). Diagnosis of postpartum depression and timing and types of treatment received differ for women with private and Medicaid coverage. Women’s Health Issues, 28(6), 524-529.