CC (chief complaint): The patient has been presented by her mother for psychiatric evaluation for moodiness following recent cases of behavioral changes and drop in academic performance. The client’s mother noticed unusual behaviors from her reactions.
HPI: Ms. Natalie Crew is a 17-year-old female American national from New Orleans presents for psychiatric evaluation for moodiness. The patient has been brought by her mother following her recent change in moods and general behavior. Her academic performance has dropped due to her difficulty in concentration and social behavior changed in recent times. Initially a social person who enjoyed interaction with her friends, Ms. Natalie’s attitude toward her friends suddenly changed and began developing antisocial characteristics. She no longer enjoys her friends’ company, but instead gets annoyed at their presence and does not find fun from anything including summertime which was her favorite. The patient is also exhibiting abnormal sleeping habits which she finds unusual. Lately, Natalie has been experiencing unique appetite for sleep, sleeping even in class. In addition, the patient has been on eating spree which has seen gaining weight at abnormal rate. She is not currently prescribed any psychotropic medications, but has been referred by her mother for evaluation and treatment.
Past Psychiatric History
General Statement: The patient has no medical history as she has never been to the hospital for similar case. Her psychiatric condition is not an old case but a recent case which developed in the past few days. The patient has confirmed to have experienced the changes only in recent times.
Caregivers (if applicable): The patient has both her parents who are responsible for providing her primary care. Besides, she has four brothers who may occasionally cheap in to provide additional care. This is evident from her mother who brought her medical evaluation and treatment.
Hospitalizations: Since the patient has never gone to the hospital or seeks medication for her before, there has never been a caregiver involved. Even though the patient has a history of depression, she has never engaged in self-harming activities such as suicide or developed suicidal thoughts.
Medication trials: The patient has never been subjected to any medical trial concerning her condition since she has never been to any medical facility or sought medical assistance from a medical personnel. Even though she has a history of depression, the patient never sought medical help for the psychological condition but battled it independently until she overcame it.
Psychotherapy or Previous Psychiatric Diagnosis
Even though the patient has no medical history from any health facility because this is her pioneer case of psychiatric condition there is a confirmed history of depression in the family. In addition, the patient has admitted to experience changes in her social behaviors and emotional status. Behaviors such as antisocial habits and regular moodiness have been confirmed by the patient. In addition, the patient has hinted about unusual sleeping habits and abnormal eating rate which has seen experience abnormal weight gain.
Substance Current Use and History
The patient has a negative substance use history for herself or family. There is no record of substance abuse in the entire family or the patient in particular. The common substance such as alcohol, caffeine, marijuana or any other hard drug has never been abused by any member of the family, the patient include.
Family Psychiatric/Substance Use History
The patient’s family history records positive of psychiatric case. Even though it is not clear which family member suffered the psychiatric condition, there is history of depression in the family. Both parents of the patient have never suffered any psychiatric condition in the past or currently. Similarly, the patient’s siblings who are four brothers have never suffered a psychiatric condition or recorded any case of substance abuse.
Psychosocial History
The patient was born in New Orleans where she spent most of her life with her four brothers under the care of her father and mother, until she moved to Chicago for high school business program. In Chicago, the patient is enrolled for full-time studies and stays within the school in one of the school dormitories. Off school, Natalie works in a local coffee shop on part time basis. The family has been staying peaceful with no record of violence among the siblings or the parents. In the same vein, the patient’s legal history is clear with no record of criminal case.
Medical History
Current Medications: The patient is not prescribed any medication or subjected to any drug before. It is the first time she is seeking medical assistance for her condition.
Allergies: The patient has no case of allergy for food, medication or environmental factors. She does not experience allergic reaction to any condition or substance.
Reproductive Hx: The patient is not lactating or expectant and has never recorded unusual menstrual occurrence or experience any problem with her menstrual periods. In addition, the patient has never been subjected to any irregular sexual practices such as anal and oral sex. Even though the patient is sexually active, she has never had a sexual experience, or have any sexual concern.
ROS
- GENERAL: The patient has undergone an abnormal rate of weight gain in the recent days which she attributes to her unique eating habits which developed recently. Additionally, the patient is exhibiting
- HEENT: Eyes; no visual loss, no blurred vision, double vision. Ears, nose, and throat have not recorded problems related to hearing loss, sneezing or unusual coughing but depict healthy working conditions.
- SKIN: No skin rushes or itching that can suggest any skin problem.
- CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort to suggest the patient is suffering from any cardiovascular disease.
- RESPIRATORY: No breathing problem related to shortness of breath
- GASTROINTESTINAL: No nausea, vomiting or diarrhea
- GENITOURINARY: No burning in urination, urgency or hesitation.
- NEUROLOGICAL: No headache, dizziness or related problems
- MUSCULOSKELETAL: No muscle, back joint, or tissue pain.
- HEMATOLOGIC: No anemia, bleeding or bruising
- LYMPHATICS: No enlarged nodes, no history of splenectomy.
- ENDOCRINOLOGIC: No reports of sweating, however the patient has history of strong hatred for cold.
- OBJECTIVE:
- Physical exam: Since the patient did not complain of or exhibit any physical health problem, there was no need to carry out physical examination.
- Diagnostic results: With no physical examination, there was not diagnostic results.
- ASSESSMENT: The patient is a 17-year-old American with low concentration and negative attitude towards her friends and general interaction to confirm antisocial behaviors. Her academic performance has dropped in school and lost her initial cognitive expertise, demonstrating her lack of concentration. The patient is exhibiting extreme sleeping habits which occasionally manifest in class to confirm changes in the sleeping habits. In addition, she has undergone abnormal rate of weight gain which is an evidence of unusual eating habits. The patient has admitted about experiencing mood swings which is a confirmation of moody behaviors.
Differential Diagnoses
Borderline personality disorder
The antisocial behaviors exhibited by the patient relates her psychiatric condition with borderline personality disorder. Besides, the lack of concentration and persistent anger are common symptoms of BPD. However, the psychiatric disorder cannot be declared as BPD due to the patient’s family history (Toliver and Anton, 2022). BPD is known to be caused by traumatic experiences in childhood such as domestic violence, child abuse or neglect which are all absent in the patient’s history.
Anxiety Disorder
The lack of concentration and emotional instability exhibited by patient makes her psychiatric condition to be closely linked with anxiety disorder. In addition, changes in the mood, characterized by anger and antisocial attitudes are other common symptoms of anxiety disorder (Etkin et al, 2022). However, the changes in sleeping and eating habits are not common among victims of anxiety disorder, but mostly found among the mood disorder patients, qualifying her case for mood disorder
Mood disorder
All the symptoms from moodiness, changes in sleeping and eating habits, antisocial behaviors and lack of concentration are clinical manifestations of mood disorder. Mood disorder is known its impact on the cognitive aspects of its patient which trigger a dropdown in the academic performance and other cognitive-related activities (Wirz-Justice, 2022). Additionally, the changes in attitude and eruptive anger point to mood disorder (Ptak and Petronis, 2022). The patient is more likely to suffer from mood disorder.
Reflections
Patients suffering from psychiatric disorders are sensitive are require high level of professional in respect to ethical considerations. Confidentiality and patient privacy are fundamental factors that must be given the deserved priority. At the same time, during examination, it is important to consider the patient factors such as age and ethnicity. It is also critical for individuals to understand the risk factors associated with most psychiatric conditions if the cases are to be minimized. Factors such as domestic violence, neglect and child abuse should be discouraged.
References
Etkin, A., Gyurak, A., & O’Hara, R. (2022). A neurobiological approach to the cognitive deficits of psychiatric disorders. Dialogues in clinical neuroscience. Web.
Ptak, C., & Petronis, A. (2022). Epigenetic approaches to psychiatric disorders. Dialogues in clinical neuroscience. Web.
Tolliver, B. K., & Anton, R. F. (2022). Assessment and treatment of mood disorders in the context of substance abuse. Dialogues in clinical neuroscience. Web.
Wirz-Justice, A. (2022). Chronobiology and mood disorders. Dialogues in clinical neuroscience. Web.