Assignment 2: comprehensive psychiatric evaluation note and patient | NRNP 6645 PSYCHOTHERAPY WITH MULTIPLE MODALITIES | Walden University
Subjective: Patient is a 24-year-old white male with no known psychiatric illness who presents for a comprehensive psychiatric evaluation. He reports difficulty sleeping, poor concentration, and feeling “down” or “flat” most days. He denies any thoughts of self-harm or suicide but states that he has been having problems functioning at work and in his personal life due to low motivation, lack of interest in things he used to enjoy, social avoidance behaviors, decrease in appetite and significant weight loss over the past few weeks. He has no medical or substance use history and takes no medications.
Objective: The patient appears well groomed and dressed appropriately for the setting. His affect was blunted; however when asked directly about his mood he described it as sad and flat with occasional periods of fleeting happiness throughout the day. Cognition appeared intact without any evidence of thought disorder or disorganization; insight was fair as patient was able to provide accurate descriptions of his symptoms despite appearing somewhat detached from them at times. No evidence of suicidal ideation was present during session but patient did disclose some passive thoughts regarding death which were assessed as non-endangering given the circumstances under which they occurred.
Assessment/diagnosis: Major Depressive Disorder (MDD) is suspected given the presence of clinically significant depressive symptoms (e.g., depressed mood/anhedonia, sleep disturbance, weight change). A full DSM-V diagnostic assessment will be completed prior to treatment planning based on further clinical information gathered over subsequent sessions.
Treatment plan: Patient will begin psychotherapy on an outpatient basis focused specifically on managing his MDD symptoms with cognitive behavioral techniques such as relaxation training and developing adaptive coping strategies for dealing with stressors both current and future ones that may arise in life situations outside our office environment (workplace dynamics etc.). Additionally patient will begin taking antidepressant medication daily starting this week under close supervision by my office staff in order to monitor effectiveness over time before making adjustments if needed; medications will be tapered off as soon as we see sufficient improvement within set parameters decided upon together earlier today e.g., reduction/elimination of depression scoring scale scores etc.. Finally I have referred him out for nutrition counseling following today’s visit given results from physical exam conducted today suggesting potential malnourishment secondary to recent changes in diet noted by clinician during initial assessment process.