For this Assignment, you will document information about a patient that you examined during the last 3 weeks, using the Comprehensive Psychiatric Evaluation Template provided. You will then use this note to develop and record a case presentation for this patient. Be sure to incorporate any feedback you received on your Week 5 and Week 7 case presentations into this final presentation for the course.
Introduction
The purpose of this assignment is to document information about a patient that was examined over the past three weeks, utilizing the Comprehensive Psychiatric Evaluation Template provided. Additionally, this information will be used to develop and record a final case presentation for the course. This assignment will incorporate feedback received on the Week 5 and Week 7 case presentations in order to enhance the final presentation.
Patient Background
The patient being discussed in this case presentation is a 45-year-old male named John. He was referred to the psychiatric clinic by his primary care physician due to concerns regarding his mental health. John has a history of major depressive disorder and was previously prescribed an antidepressant medication. He is currently divorced and lives alone. John has a Master’s degree in Accounting and works as a senior financial analyst for a large corporation.
Presenting Problem
John presents with symptoms of low mood, loss of interest in activities, feelings of hopelessness, and difficulty sleeping. These symptoms have been present for the past six months and have been affecting his daily functioning. John has reported a significant decline in his work performance and has been experiencing conflicts with his co-workers due to his irritability. He also mentioned feelings of guilt and worthlessness, as well as thoughts of self-harm. John reports having difficulty concentrating and making decisions, and he feels exhausted despite getting enough sleep.
Psychiatric History
John has a history of major depressive disorder, with his first episode occurring in his late twenties. He was successfully treated with a combination of medication and psychotherapy at that time. However, he discontinued treatment after a few months and did not seek further help until now. John also has a family history of depression, as his mother and younger sister have both been diagnosed with the disorder.
Medical History
John has a history of hypertension, which is managed with medication. He does not have any significant medical illnesses or surgeries. He denies any history of substance abuse.
Substance Use History
John denies any current or past substance abuse. He reports occasional alcohol use, typically consuming one to two drinks per week. He does not use illicit drugs.
Social History
John is divorced and lives alone in an apartment. He has two adult children who live in another state. John describes his relationship with his ex-wife as strained, stating that she often belittled him during their marriage. He does not have a significant support system and feels socially isolated. John mentions feeling lonely and has difficulty initiating and maintaining social relationships.
Mental Status Examination
During the mental status examination, John appeared sad and tearful. His speech was slow and his affect was constricted. He exhibited psychomotor retardation, with slowed movements and decreased body language. John displayed signs of impaired concentration and attention, as he had difficulty staying focused during the interview. His thought processes were characterized by negative and self-deprecating content, as he expressed feelings of guilt and worthlessness. No abnormal perceptions or delusions were reported.
Diagnosis and Treatment Plan
Based on the information obtained from the psychiatric evaluation and John’s history, a diagnosis of major depressive disorder, recurrent, moderate is established. The treatment plan for John includes a combination of pharmacotherapy and psychotherapy. An antidepressant medication will be prescribed, considering John’s previous positive response to medication. Additionally, cognitive-behavioral therapy will be initiated to address his negative thought patterns and teach adaptive coping strategies.
Conclusion
This case presentation has provided an overview of John’s background, presenting problem, psychiatric history, medical history, substance use history, social history, and mental status examination. The diagnosis of major depressive disorder, recurrent, moderate has been established, and a treatment plan incorporating pharmacotherapy and psychotherapy has been developed. This final presentation incorporates feedback received on previous case presentations and aims to present a comprehensive understanding of the patient’s condition and proposed interventions.