NRNP 6635 Assessing and Diagnosing Patients With Mood Disorders

Sample Answer for NRNP 6635 Assessing and Diagnosing Patients With Mood Disorders Included After Question

By Day 7 of Week 3

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

A Sample Answer For the Assignment: NRNP 6635 Assessing and Diagnosing Patients With Mood Disorders

Title: NRNP 6635 Assessing and Diagnosing Patients With Mood Disorders

Subjective:

CC (chief complaint): Allegations by the patient’s mother that the patient recurrently gets moody this time of the year every year.

HPI: Ms. Julie Houston is a 19-year-old female who came to the psychiatric clinic for assessment following a recommendation from her mother. The patient presented with allegations by her mother that she recurrently gets moody around this time of the year annually. She reports that she is not feeling great and feels down. She admits to not doing so well, especially with her special business program in school. She reports that she comprehends everything but the classes are boring. She feels the teachers are stressing her with projects such as developing a mock company which she is finding difficult to complete. Two of the projects are already long overdue. The patient reports difficulty concentrating. For instance, she can read newspaper headlines and cannot seem to recall them almost immediately, a similar case with her classes.

The patient has recently gained weight approximately ten pounds. She is experiencing excessive daytime sleepiness to an extent of sleeping through five of her classes this month. Initially, the patient was social, and easily made a lot of friends with whom she enjoyed their company. She would attend concerts and shows with them and engage in fun activities. However, lately, she finds them annoying, and dull and avoids their company. She currently prefers staying indoors alone which she partly attributes to the cold weather. She expresses her dislike for fall and winter because she cannot engage in activities such as going to the beach and riding in convertibles which she usually does during summer. She associates winter with darkness, and misery as opposed to beauty during summer.

Past Psychiatric History:

  • General Statement: The patient denies any past psychiatric treatment.
  • Caregivers (if applicable): Her parents.
  • Hospitalizations: The patient has never had any psychiatric admissions.
  • Medication trials: She is not on any medication trials.
  • Psychotherapy or Previous Psychiatric Diagnosis: The patient has never been diagnosed with any psychiatric disorder or undergone psychotherapeutic interventions.

Substance Current Use and History: The patient denies any history of or current substance abuse or abuse by any member of her family.

Family Psychiatric/Substance Use History: There is no history of any psychiatric condition in her immediate or extended family.

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Psychosocial History: The patient grew up in South Carolina and was raised by both her parents. She has three other siblings, two brothers, and one sister. She is currently a full-time student undertaking a business undergraduate program in Boston. She stays with two other female student roommates in off-campus housing. She is unemployed, has never been married, and not dating. She has no history of legal issues or trouble with the authorities.

NRNP 6635 Assessing and Diagnosing Patients With Mood Disorders
NRNP 6635 Assessing and Diagnosing Patients With Mood Disorders

Medical History: The patient has never been admitted for any medical treatment.

  • Current Medications: She is not on any prescription medication for any medical condition.
  • Allergies:She has no known allergies to drugs or drugs.
  • Reproductive Hx:Her menarche was at fourteen years. She experiences a regular menstrual cycle. Her last menstrual period was 20 days ago. She is not currently gravid. She has never used any contraceptives and has no children.

ROS:

  • GENERAL: The patient reports no weight loss but a recent weight gain, no fever, and no generalized weakness.
  • HEENT: There is no vision loss, hearing loss, dysphagia, sore throat, or nasal congestion.
  • SKIN: The patient denies pruritus, skin rash, or abnormal skin changes.
  • CARDIOVASCULAR: There are no reported palpitations, easy fatigability, shortness of breath even on exertion, chest pain, or edema.
  • RESPIRATORY: There is no difficulty in breathing, no chest pain, and no cough.
  • GASTROINTESTINAL: The patient denies experiencing anorexia, abdominal pain, nausea, vomiting, diarrhea, or constipation.
  • GENITOURINARY: Patient reports no pain or discomfort on urination, blood in urine, increased frequency, or incontinence.
  • NEUROLOGICAL: The patient denies headaches, dizziness, numbness, convulsions, weakness, or paralysis.
  • MUSCULOSKELETAL: There are no myalgias, no joint swelling, pain, or stiffness.
  • HEMATOLOGIC: The patient denies anemia or excessive bleeding tendency.
  • LYMPHATICS: There are no swollen lymph nodes or enlarged spleen.
  • ENDOCRINOLOGIC: The patient denies intolerance to heat or cold, polyuria, polydipsia, polyphagia, or excessive sweating.

Objective:

Physical exam:

Vital signs: Temperature 98.1, PR-78, RR-18, BP 119/74 Ht 5’2” Wt 184lbs

General: The patient is in fair general condition, is not in any form of distress, is well nourished and is well-kempt.

HEENT: The head is normocephalic, pupils are equally reactive to light, the oral cavity is of good hygiene and free of inflammatory processes, ear canals are clear, and the nose is not congested.

Neck: The neck is soft with no masses, no cervical lymphadenopathy, no thyroid swelling, and no distended neck veins.

Chest/Lungs: The chest moves with respiration, and expands symmetrically, vesicular breath sounds are heard on auscultation with good bilateral air entry. 

Heart/Peripheral Vascular: The precordium has normal cardiac activity, the apex beat is not displaced, and first and second heart sounds were heard with no added sounds or murmurs.

Abdomen: The abdomen is not distended, not tender, with no abnormal masses, hepatomegaly, and no splenomegaly. Bowel sounds are present.

Genital/Rectal: Findings from a digital rectal examination were normal.

Musculoskeletal: There is no limitation in the range of movement in all joints. No swelling, stiffness, deformity, or tenderness was noted.

Neurological: Cranial nerve assessment is normal. Motor examination of bulk, tone, power, and reflexes are normal. Sensory examination is intact.

Skin: The skin has no lesions or abnormal changes.

Diagnostic results:

Complete blood count revealed values of cell counts that were within normal ranges.

A toxicology screen of blood and urine samples was negative for any drug.

No organisms were isolated from blood cultures.

Random blood sugar showed serum glucose levels that were within normal ranges.

Thyroid function tests were within normal values.

Blood urea, nitrogen, and creatinine were within normal levels.

Liver function tests were non-contributory.

A head CT scan detected no cranial pathology.

Assessment:

Mental Status Examination: The patient is a 19-year-old female who looks appropriate to her stated age. She is well-groomed and appropriately dressed. She is alert and fully cooperates with the examiner. There is no evidence of motor agitation. Her orientation to place, person, and time is intact. Her speech is clear, coherent, and of normal tone, rate, and volume. She has a depressed mood which is congruent with her affect. She exhibits no evidence of flight of ideas or looseness of association.

She experiences occasional suicidal thoughts but has no intention of harming herself or others. She has no auditory or visual hallucinations, or delusions. Her immediate and recent memory is impaired evidenced by not remembering newspaper headlines five seconds after reading them and not recalling what she learns from her classes. Her remote and long-term memory is intact. Her concentration is poor. She lacks insight into her condition. Her judgment is good.

Differential Diagnoses:

1. Bipolar disorder: This is the most likely diagnosis in this patient. This is because the patient exhibits a combination of manic and depressive episodes (Jain et al., 2022). The patient initially experienced a manic episode characterized by elevated mood, increased activity, decreased need for sleep, and increased sociability (Faurholt-Jepsen et al., 2020). During this phase, she could easily make friends and engage in fun activities. The depressive episode that the patient is currently in is characterized by a depressed mood, loss of interest in activities that she initially enjoyed, weight gain, hypersomnia even during classes, reduced concentration, suicidal thoughts, and pessimistic views (Tolentino et al., 2018).

The mood disturbance is severe enough to an extent of causing social and functional impairment (Jain et al., 2022). This is evidenced by isolation from her friends whom she initially had cordial relations with. The patient is also having trouble completing her program projects. Bipolar disorder has two incidence peaks of onset the first one being between 15 to 24 years and the second peak occurring between 45 to 54 years (Rowland et al., 2018). The patient is 19 years thus is more predisposed to the first peak. The report by the patient’s mother that the patient gets moody at the same time every year supports the cyclic nature of the condition.

2. Depressive disorder: This is the other probable diagnosis. The symptoms that the patient is currently presenting with are typical of depressive illness. This is supported by the aforementioned symptoms such as depressed mood, reduced energy, suicidal thoughts, and sleep disturbance. The risk factors that predispose to depressive illness that are present in this patient include age, female gender, previous episode based on information from the patient’s mother and stress that probably stems from the program projects (Park et al., 2019). This diagnosis does not, however, explain the experience of manic symptoms.

3. Borderline Personality Disorder: The patient may also be having a borderline personality disorder. This disorder usually presents with pervasive affective instability, impulsiveness, suicidal thoughts, and unstable interpersonal relationships that were evident from the history (Kulacaoglu et al., 2018). This diagnosis does not explain the presence of other depressive symptoms such as hypersomnia and depressed mood.

Reflections: The examiner in this case scenario was remarkable in eliciting important information from the patient that guided the formulation of the diagnosis. Involving the patient’s mother provided corroborative information that filled any gaps in the psychiatric assessment. Privacy and confidentiality of the patient were maintained by conducting the assessment in a room with minimal personnel flow. The patient has never been on any psychiatric treatment thus the formulation of the treatment plan will require the provision of adequate information for an informed choice.

There should be no coercion in decision-making regarding the treatment approach. The patient is a teenager thus the involvement of the parents in shared decisions may be necessary. Medication trials that will be considered should be beneficial to the patient with minimal risks. The patient lacks insight thus the need for psychoeducation and education on the need for adherence to treatment recommendations. The patient expresses suicidal thoughts thus as an examiner, I would have further explored the suicide risk such as enquiring about previous attempts or intent.

References

Chapman, J., Jamil, R. T., & Fleisher, C. (2022). Borderline Personality Disorder. In StatPearls. StatPearls Publishing.

Faurholt-Jepsen, M., Christensen, E. M., Frost, M., Bardram, J. E., Vinberg, M., & Kessing, L. V. (2020). Hypomania/Mania by DSM-5 definition based on daily smartphone-based patient-reported assessments. Journal of affective disorders, 264, 272–278. https://doi.org/10.1016/j.jad.2020.01.014

Jain, A., & Mitra, P. (2022). Bipolar Affective Disorder. In StatPearls. StatPearls Publishing.

Kulacaoglu, F., & Kose, S. (2018). Borderline personality disorder (BPD): Amid vulnerability, chaos, and awe. Brain Sciences, 8(11), 201. https://doi.org/10.3390/brainsci8110201

Park, L. T., & Zarate, C. A. (2019). Depression in the primary care setting. New England Journal of Medicine, 380(6), 559–568. https://doi.org/10.1056/nejmcp1712493

Rowland, T. A., & Marwaha, S. (2018). Epidemiology and risk factors for bipolar disorder. Therapeutic Advances in Psychopharmacology, 8(9), 251–269. https://doi.org/10.1177/2045125318769235

Tolentino, J. C., & Schmidt, S. L. (2018). DSM-5 criteria and depression severity: Implications for clinical practice. Frontiers in Psychiatry, 9. https://doi.org/10.3389/fpsyt.2018.00450

A Sample Answer For the Assignment: NRNP 6635 Assessing and Diagnosing Patients With Mood Disorders

Title: NRNP 6635 Assessing and Diagnosing Patients With Mood Disorders

Subjective:

CC (chief complaint): “Everyone keeps saying I have PTSD.”

HPI: R.C. is a 25-year-old female patient who presented to the psychiatric clinic for evaluation of post-traumatic stress disorder (PTSD). She claims that everyone, including her boyfriend, with whom they served in the military, thinks that she has PTSD. She reports a history of depression at the age of 13 or 14 years which was managed with antidepressants. She however stopped taking the medication at the age of 18 years so that she could be enlisted. She denies being in combat but claims to have helped load the body bags of soldiers into the plane, which is recurrent in her mind, making her sad. She reports being depressed since she was 18, and it worsens when on her periods. She also reports sleeping difficulties, recurrent thoughts of the dead soldiers, reduced appetite, reduced concentration levels, crying spells, self-guilt, being a disappointment, low energy levels, social phobia, and reduced interest. Denies suicidal thoughts or nightmares.

Past Psychiatric History:

  • General Statement: The patient reports a diagnosis of depression at the age of 13 or 14 years. She has been managing her symptoms with antidepressants until the age of 18 years.
  • Caregivers (if applicable): The patient stays with her boyfriend off base.
  • Hospitalizations: Reports no history of hospitalization.
  • Medication trials: Reports taking sertraline and fluoxetine both of which were effective in managing her depression until the age of 18 years, when she stopped taking them for her to be enlisted in the military.
  • Psychotherapy or Previous Psychiatric Diagnosis: Report a history of depression diagnosis at the age of 13 or 14 years. No history of psychotherapy was reported.

Substance Current Use and History: No history of drug use was reported.

Family Psychiatric/Substance Use History: Brother with a history of cannabis use. Mother with a history of depression.

Psychosocial History: The patient was born and raised in McAllen TX with both her parents and an elder brother. She currently lives with her boyfriend off base in El Paso, Texas. She graduated high school and currently serves in the Army, MOS 92M Mortuary Affairs Specialist. She has no children. 

Medical History: No history of any other medical problem reported at the moment.

  • Current Medications: Denies use of any drug for her depression currently.
  • Allergies:Reports ciprofloxacin allergy. No food or environmental allergies.
  • Reproductive Hx:Heterosexual with one partner. No children. Regular menses are reported, which worsens her depression.

ROS:

  • GENERAL: No headache, changes in body weight, fatigue, or malaise.
  • HEENT: Head: atraumatic. Eyes: No visual changes, blurred vision, use of corrective lenses, or red/itchy eyes. Nose: No congestion, irritations, inflammation, nose bleeding, or sinus problems. Throat & Mouth: No sore throat, bleeding gums, or swallowing difficulties.
  • SKIN: Denies discoloration, hives, rashes, blisters, lumps, or ulcers.
  • CARDIOVASCULAR: Denies chest pressure, pain, edema, or palpitations.
  • RESPIRATORY: No wheezing, sneezing, dyspnea, coughing, or chest congestion.
  • GASTROINTESTINAL: No abdominal pain, hernia, constipation, diarrhea, or changes in bowel movement.
  • GENITOURINARY: Negative for abnormal PV discharge, dysuria, or urinary urgency/frequency.
  • NEUROLOGICAL: No headache, changes in vision, loss of consciousness, or dizziness.
  • MUSCULOSKELETAL: Exhibits full ranges of movement in both upper and lower extremities. No joint stiffness or pain.
  • HEMATOLOGIC: No bleeding problems or prolonged healing of wounds.
  • LYMPHATICS: No signs of enlarged lymph nodes.
  • ENDOCRINOLOGIC: Denies polyuria, polyphagia, or polydipsia. No hypothyroidism.

Objective:

Physical exam: Vitals: T-97.7 P-70 R-18 118/72 Ht 5’3 Wt. 123lbs

Diagnostic results: Routine blood tests were ordered including hemoglobin test, complete blood count, basic metabolic panel, blood glucose level, and basic metabolic panel. Thyroid tests are also ordered to determine whether the patient’s symptoms are associated with hormonal imbalances. Liver function tests and kidney function tests were also necessary for decisions concerning psychotropic medications to prescribe. Imaging studies including X-Ray and CT scan of the head taken to assess for anatomical deformities or trauma, which might also contribute to the patient’s symptoms. Additional screening tools utilized include the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) and the Patient Health Questionnaire (PHQ)-2 and PHQ-9 (Strawbridge & Young, 2022).

Assessment:

Mental Status Examination: The patient walks to the psychiatric unit well-groomed in age-appropriate clothing. Her orientation in time, place, and person is appropriate. She is cooperative during the interview and talks in a normal tone. She seems distracted with a reduced concentration level. Her affect is congruent, with a sad mood. Her thought process is intact, with appropriate perception. Her judgment is age-appropriate, providing reliable answers during the interview. Her short-term and long-term memory are intact. She confirms being depressed, with social phobia. Denies hallucinations, nightmares, suicidal ideation, or injurious behavior.

Differential Diagnoses:

  1. Major Depressive Disorder: According to the DSM-V, the diagnosis of MDD requires the patient to report not less than five of the following symptoms for the same duration of at least two weeks with at least one of the symptoms being the loss of interest/pleasure or depressed mood: diminished interest in activities, depressed mood, changes in body weight, worthlessness, reduced concentration, and recurrent thoughts of death (Pan et al., 2018). The patient is positive for most of these symptoms in addition to a history of depression which makes this diagnosis the most probable primary diagnosis.  
  2. Post-Traumatic Stress Disorder: For the diagnosis of PTSD, the DSM-V outlines that patient must have encountered a traumatic experience leading to symptoms that fall into the four categories, negative mood and thought changes, intrusion avoidance, and changes in reactivity and arousal (Carmassi et al., 2020). The patient reports helping load body bags of soldiers but denies having nightmares about them.
  3. Social Anxiety Disorder: The DSM-V diagnostic criteria for SAD comprise anxiety or intense and persistent fear regarding special social situations that may be due to the feeling of being embarrassed (Koyuncu et al., 2019). The patient reported the fear of getting out of the house or going to any social place.

Reflections: The PMHNP collected adequate information from the patient necessary in coming up with a possible primary diagnosis. However, since the patient was mainly concerned about the claims that she has PTSD, the clinician would have administered the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) to confirm or rule out this diagnosis (Adams et al., 2021). The patient being an adult gives them the legal right to make decisions concerning her help. The PMHNP is also required to uphold the patient’s autonomy. As such, the clinician must explain to the patient adequately about his symptoms, and the most possible diagnosis in addition to available treatment options. The patient should also be educated adequately on exercise and sleep as part of health promotion practices and the need to comply with the treatment regimen to promote a positive outcome.

References

Adams, R. E., Hu, Y., Figley, C. R., Urosevich, T. G., Hoffman, S. N., Kirchner, H. L., Dugan, R. J., Boscarino, J. J., Withey, C. A., & Boscarino, J. A. (2021). Risk and protective factors associated with mental health among female military veterans: results from the veterans’ health study. BMC Women’s Health21(1). https://doi.org/10.1186/s12905-021-01181-z

Carmassi, C., Bertelloni, C. A., Cordone, A., Cappelli, A., Massimetti, E., Dell’Oste, V., & Dell’Osso, L. (2020). Exploring mood symptoms overlap in PTSD diagnosis: ICD-11 and DSM-5 criteria compared in a sample of subjects with Bipolar Disorder. Journal of Affective Disorders276, 205–211. https://doi.org/10.1016/j.jad.2020.06.056

Koyuncu, A., İnce, E., Ertekin, E., & Tükel, R. (2019). Comorbidity in social anxiety disorder: diagnostic and therapeutic challenges. Drugs in Context8, 1–13. https://doi.org/10.7573/dic.212573

Pan, J.-X., Xia, J.-J., Deng, F.-L., Liang, W.-W., Wu, J., Yin, B.-M., Dong, M.-X., Chen, J.-J., Ye, F., Wang, H.-Y., Zheng, P., & Xie, P. (2018). Diagnosis of major depressive disorder based on changes in multiple plasma neurotransmitters: a targeted metabolomics study. Translational Psychiatry8(1). https://doi.org/10.1038/s41398-018-0183-x

Strawbridge, R., & Young, A. (2022). Care pathways for people with major depressive disorder. European Psychiatry65(S1), S620–S620. https://doi.org/10.1192/j.eurpsy.2022.1587