Psychiatric Evaluation: The Case Study Essay

• CC (chief complaint): The patient claims that she has “insufficient concentration of attention and its frequent fluctuations, leading to rapid fatigue during mental work, pauses and stops of current activity.”
• HPI: P.H., a 19-year-old Hispanic female, presents for psychiatric evaluation for concentration difficulty. She is not currently prescribed psychotropic medications. She is referred by her therapist for medication evaluation and treatment.
• Past Psychiatric History:
  • General Statement: The girl entered treatment at age 14 with counseling for depression (the main symptoms were strong negative emotions and feelings, loss of interest, fatigue, low self-esteem, indecision, suicidal thoughts, as well as changes in sleep, appetite, and weight) during her parents’ divorce.
  • Caregivers (if applicable): The patient’s mother — a family member.
  • Hospitalizations: The girl was hospitalized once, at the age of 14, in the hospital of the local medical organization. The patient’s hospitalization was due to a persistent sleep disturbance, loss of the essence of life, the appearance of “bad” suicidal thoughts, and the desire to injure her body. Detoxifications were not observed. A wide range of inpatient procedures was implemented, such as high doses of antipsychotics and antidepressants in combination with physiotherapy and physical therapy. The last residential treatment was carried out in the local hospital five years ago. The therapy regimen lasted three weeks and allowed to achieve a visible improvement in the patient’s condition, after which P.H. was transferred to outpatient treatment. Indeed, there have been both suicidal and self-harm behaviors in history.
  • Medication trials: The patient had previously tried antidepressants as fluoxetine (Prozac™); the reaction was effective.
  • Psychotherapy or Previous Psychiatric Diagnosis: The patient is aware of the type under ethical principles and recognizes psychotherapy as a valuable, effective method for treating clinical depression due to improving well-being and positively changing the perception of the surrounding reality.
• Substance Current Use and History: There is an active use of caffeine (3 cups a day) and nicotine (3 cigarettes a day). The girl does not use psychotropic substances, and there were no withdrawal complications.
• Family Psychiatric/Substance Use History: One established that the patient’s mother had previously had a depressive disorder, including one associated with using psychoactive substances. It is assumed that the genes have a polygenetic character and are one of the reasons for the manifestation of clinical depression in the girl (Shadrina et al., 2018).
• Psychosocial History: It is known that the girl was born in the USA and was raised by her mother and father. The patient has a younger brother and an older sister and treats each family member positively, but sometimes conflicts may arise between them. Currently, the patient lives with her mother, brother, and sister; she is single and has no children. Presently she is studying in college and has an incomplete higher education; she is unemployed. Furthermore, she is engaged in needlework, knitting, photography, and singing. P.H. has never had problems with the law before and has not faced legal issues. Previously, minor physical injuries were noted. Domestic violence is an unacceptable phenomenon; the girl feels safe at home.
• Medical History: The girl had not previously experienced significant surgeries.
• Current Medications: It is assumed that the girl has ADHD and was prescribed particular medications. She uses over-the-counter Brillia and takes one or two tablets twice daily for three weeks due to a lack of proper concentration. In addition, the patient actively turns to natural ways to focus on educational and other tasks through non-medical treatment, such as exercises, listening to music, or doing work in the presence of the loved one (Scheck, 2021).
• Allergies: It is noted that the girl is not allergic to the food consumed and to the medications prescribed by a healthcare specialist.
• Reproductive Hx: The menstrual cycle is regular, and no deviations were found, as well as sexual problems.
• ROS:
  • GENERAL: There is slight weight loss, apathy, and fatigue during the day.
  • HEENT: Diseases of the eyes, ears, throat, and nose are not observed.
  • SKIN: The skin is in normal condition, without itching, with a slight rash on the body.
  • CARDIOVASCULAR: There is no pain and discomfort in the chest.
  • RESPIRATORY: Normal breathing rate, ranging from 12 to 20 breaths per minute; no symptoms of difficulty breathing.
  • GASTROINTESTINAL: Digestive disorders, decreased appetite, and nausea were noted.
  • GENITOURINARY: Burning on urination.
  • NEUROLOGICAL: The girl has periodic headaches and isolated cases of dizziness.
  • MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness.
  • HEMATOLOGIC: No anemia, bleeding, or bruising.
  • LYMPHATICS: No enlarged nodes. No history of splenectomy.
  • ENDOCRINOLOGIC: The patient reported a frequently manifested feeling of cold and a desire to warm up.
• Physical exam: if applicable.

Diagnostic results

Assessment

Mental Status Examination: The young 19-year-old girl of Spanish origin looks well-groomed and neat. She is not conflicted, makes contact, competently, and calmly answers questions. The speech is clear and coherent; there is an understanding of the meaning of the specialist’s speech. However, the girl was sometimes inattentive, and it was difficult for her to concentrate on listening to a long speech. Moreover, she distinguished herself by some hyperactivity, often fidgeted in her chair, could not sit still, and actively gesticulated when answering several questions.

Differential Diagnoses: In general, the girl may have ADHD, anxiety, or a traumatic brain injury. However, absent-mindedness and hyperactivity/impulsivity are vital behaviors that distinguish a patient with ADHD (Mayo Clinic Staff, 2019). At the same time, the girl demonstrates both behaviors – both absent-mindedness and hyperactivity-impulsivity (Mayo Clinic Staff, 2019). At the same time, the girl may have anxiety because she feels constant fatigue, insomnia, fear, inability to concentrate, inability to relax, irritability, and dizziness. The girl can also hide a traumatic brain injury, contributing to increasing general weakness, drowsiness and lethargy, retrograde amnesia, nausea, and gastrointestinal problems.

Reflections

The student agrees with the mentor’s assessment, expressing gratitude for honesty and objectivity, and also partially concurs with the diagnostic impression of the patient since a thorough and thorough examination is necessary before making accurate conclusions. From this case, the student learned about the specifics of the work of compiling the characteristics of the patient, his complaints, medical history, and other equally important aspects. The student would additionally add questions and interviews with the patient, asking about the time at which the ailments manifest themselves, as well as in more detail about activities and relationships with other people.

Indeed, the information presented is closely related to legal and ethical aspects since it is only an approximate analysis of the patient and an attempt to determine the state of health and the human body. The work touches on the social determinants of health, discussing the patient and the environment in which he lives, studies, and interacts with others. Moreover, it is worth mentioning separately about health promotion and disease prevention, considering the patient’s factors based on age and ethnic group, since the intended treatment, actions, symptoms, and other aspects were associated with similar data about the patient. PMH and other risk factors were also discussed, taking into account the mental and psychological characteristics of the patient both in the past and present.

References

Shadrina, M., Bondarenko, E. A., & Slominsky, P. A. (2018). Genetics factors in major depression disease.Frontiers in Psychiatry, 9, 334.

Scheck, A. (2021). All-natural ways to focus better with ADHD. ADDitude Magazine. Web.

Mayo Clinic Staff. (2019). Adult attention-deficit/hyperactivity disorder (ADHD). Mayo Foundation for Medical Education and Research (MFMER).