Assessing and Diagnosing Patients With Mood Disorders.

Complete and submit your Comprehensive Psychiatric Evaluation, including your differential diagnosis and critical-thinking process to formulate a primary diagnosis. Incorporate the following into your responses in the template: 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 the patient’s mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses with supporting evidence, listed in order from highest priority to lowest priority. Compare the DSM-5 diagnostic criteria for each differential diagnosis and explain what DSM-5 criteria rules out the differential diagnosis to find an accurate diagnosis. Assessing and Diagnosing Patients With Mood

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Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case. Reflection notes: What would you do differently with this client if you could conduct the session over? Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).

CC (chief complaint): “I have been having some headache for 6-7 months”.Assessing and Diagnosing Patients With Mood Disorders.

HPI: L.K  is a middle aged male presenting himself in the clinic for an increased headaches for 6-7 months. Previously, the client reports to have been having stomach problems. The patient reports to easily gets annoyed easily by his girlfriend whenever she starts a lot of things. He reports having a noise problem that began in the past six months. More so, the client reports to have been worrying too much whenever his girlfriend drives to an extend of screaming thinking she could cause an accident. Still, the client has been losing interest of any activity happening around him. He also reports of feeling guilty whenever he thinks of being around with his family. Currently, the patient is not subscribed to any psychotic medication. He is refered by ownself to seek medication and treatment in the clinic.Assessing and Diagnosing Patients With Mood Disorders.

Past Psychiatric History: None

Substance Current Use and History: None

Family Psychiatric/Substance Use History: Both parents

Psychosocial History: The patient was born and raised by his parent. The client is the first in a family of two sibling. The other sibling is 17 years and live with the parents. The patient lives with his girlfriend in a house they bought together. Currently, the coulple don’t have a child. Both of them share some of the classes they attend every morning while driving daily. The patient experience fear fearing when his girlfriend is driving thinking she might cause an accident. Currently, the patient gets annoyed out of anything done around him.Assessing and Diagnosing Patients With Mood Disorders.

Medical History:

• Current Medications: None
• Allergies: No allergies reported
• Reproductive Hx:

ROS:

• GENERAL: positive headache; no fever, no chills or sweats, no weight gains of losses of significance
• HEENT: Reported headache, no visual issues, no running nose, no pain when swallowing, no sore throat, does not use glasses, and no hearing complications.
• SKIN: No rashes and itchness
• CARDIOVASCULAR: no palpitations or edema, absence of pressure and chest discomfort.Assessing and Diagnosing Patients With Mood Disorders.

RESPIRATORY:  No running nose. No congestion and breath shortness, no hoarseness.

• GASTROINTESTINAL: no decreased appetite, no vomiting and nausea, no abdominal pain, no changes in bowel
• GENITOURINARY: consistent urinary pattern
• NEUROLOGICAL: no dizziness , no paralysis , +headaches, no abdominal disturbance history, No memory loss patterns;, no change in bowel. No numbness in extremist.
• MUSCULOSKELETAL: no fracture history, reports no joint pain, no muscle pain and stiffness.
• HEMATOLOGIC: No anemia, no bleeding, or bruising.
• LYMPHATICS: -ve throat scratchiness, tender lymph; no bleeding, no history of blood transfusion.
• ENDOCRINOLOGIC: no report of intolerance case of sweat, cold or heat.Assessing and Diagnosing Patients With Mood Disorders.

Physical exam:

Diagnostics: blood test

Determines the level of GAD antibodies in the blood.

Diagnostic results: 6 units/ml

Assessment

Mental Status Examination: The patient is a middle aged white male and seem to be cooperative and active when interacting with the examiner. He is dressed approprietly, and neatly groomed. The client doe not indicate any evidence of abnormality. He derivers a clear speech in a coherent and in a normal tone. His ideas and thought are subjeted in a logical manner. His face seem to have a calm profile. He denies to have visual hallucination or auditory issue. He claims to have been experiencing a headache during the time of the interview. Cognitively he is oriented as well as alert. His memory of past things is intact and have a good insight.Assessing and Diagnosing Patients With Mood Disorders.

Differential Diagnoses:

Generalized Anxiety Disorder(GAD): GAD illness is characaterised by both the psychological and physical symptoms (Qin et al., 2019). The psychological clinical features include restlessness, tension, difficulty concentrating, being irritable, difficulty controlling feelings of worry and a sense of dread. According to Duijndam & Denollet, (2019) GAD symptoms result to withdrawal from social contacts such as girlfriend, friends and family as evident in the client’s case. The physical symptoms evident in the patient are headache, tension, nervousness, irritability and stomachache.Assessing and Diagnosing Patients With Mood Disorders.

Post-traumatic stress disorder (PTSD): This disorder is associated with frightening thoughts of events such as accidents (Hendawy et al., 2020). The client experiences such thoughts and has resulted to avoiding driving since it increases tension and flashbacks of accidents. He feeling tensed, experiences angry outbursts and has negative thoughts about oneself and others. He has distorted feelings like guilt of not seeing his family frequently and also blames his girlfriend of many things he feels she does wrong such as breathing hard. He has lost interest in enjoyable events is hypervigilance’, irritabile and expereinces concentration problems.Assessing and Diagnosing Patients With Mood Disorders.

Panic disorder: The client has been suffering abdominal cramping for at least a year. He has a persistent headache, fears losing control or death. He demonstrates panic disorder complications attributed like phobia of driving, avoidance of social situation and anxiety disorders (Andrews et al., 2018).Assessing and Diagnosing Patients With Mood Disorders.

The most appropriate diagnosis for the patient is GAD cormobid with PTSD

Compare the DSM-5 diagnostic criteria for each differential diagnosis and explain what DSM-5 criteria rules out the differential diagnosis to find an accurate diagnosis

The DSM-5 criteria for diagnosing a type of depression put a criteria that one should be experiencing more than three symptoms in a period of 2 weeks with either a depressed mood or loss of pleasure or interest (Nussbaum, 2020, December). Assessing and Diagnosing Patients With Mood Disorders.Therefore, in this case the patient is characterized with diminished interest with whatever is around him including his girlfriend. Generalized anxiety disorder as associated feature it is characterized with irritability, excessive worries, and complain of pain. Still, according to DSM-5 diagnostic criteria generalized anxiety disorder meets diminished abiity to concentrate (Panganiban et al., 2018). This is revealed by the presented case where the patient cannot concentrate while reading while the girlfriend is in next room. Also, he gets affected with dogs noises as well as neighbours emptying trash. Still, the client is found to have a guilt feeling this also meets a DSM-5 criteria of diagnosis. another criteria that the most probable diagnosis meet is that the patient is having recurrent thoughts of death mostly when his girl friend is driving.Assessing and Diagnosing Patients With Mood Disorders.

Post-traumatic stress disorder meet the DSM-5 criteria for diagnosis on how the patient is associating himself with frightening thoughts. Presense of such thought is one of the criteria for diagnosis since he goes ahead avoiding driving whenever they travels together with his girlfriend. Next, this condition meet diminished interest in almost all activities. This criteria meets the patient current status since she first loses his interest to his pretty girl friend. This disorder only reveals to meet less than three criteria according to the DSM-5 criteria for disorders and thus it is eliminated as the main disorder in the presented case study.Assessing and Diagnosing Patients With Mood Disorders.

Panic disorder meets the DSM-5 criteria for diagnosis by first revealing the patient has been suffering with abdorminal pain (Clark et al., 2017). Besides, the patient has been complaining of having phobia when driving and this meets the recurrent thought of death from previous accident he ealier had experienced. This disorder only meets the criteria with only two approvals and therefore it does not meets the DSM-5 threshold.Assessing and Diagnosing Patients With Mood Disorders.

Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.

In selecting the primary diagnosis I was guided with critical thinking process that involved clinical reasoning on the basis of the presented case. By employing my clinical knowledge I was able to determine the client’s health problem. First, I developed a decision making model that involves gathering of necessary information from the patient, integration of the collected data, interpretation, and working on the probable diagnosis (Kalid et al., 2018).Assessing and Diagnosing Patients With Mood Disorders. diagnosis process starts by considering the patient’s signs and symptoms within health context. To remain with a working diagnosis in this context then I had to list some of the probable diagnosis. Then with application of clinical knowledge was able to eliminate some diagnosis based on the patients symptoms and this gave a definite result further as I continue with diagnostic process (Norman et al., 2017). In addition, the process was aided by presence of pertinent positive that involved presence of fear and guilt this enabled ruling out of the disorder easily. On the other hand, pertinent negative involved no weight loss or loss of appetite.Assessing and Diagnosing Patients With Mood Disorders.

Reflections: According to my reflection in this case, I would require more information from the family members to seek more history to know if there is anyone with such a condition. More so, on ethical consideration on the case study going beyond critical thinking confidentiality aspect should be maintained by the psychiatrist on the fact that client could not wish to be seen by anyone. Still, on consent for treatment the psychiatrist should treat the client by engaging the patient fully (Penzenstadler et al., 2019).Assessing and Diagnosing Patients With Mood Disorders.