NRNP 6635 Assignment: Assessing and Diagnosing Patients With Mood Disorders

NRNP 6635 Assignment: Assessing and Diagnosing Patients With Mood Disorders

Subjective:

CC (chief complaint): “I feel down.”

HPI:

Natalie Crew is a 17-year-old female presenting to the psychiatric clinic with reports of feeling down. Natalie’s mother thought she should visit the counselor because she is worried that she gets moody this time of year, every year. However, Natalie is not sure if the reports are true. She states that she is not great and feels down. Natalie reports that she left school because she is not doing so well. She says the courses were not challenging, but the teachers piss her off. Besides, she seems not to understand how to develop a mock company of a project in a special business program she is undertaking. She is also late on two of her school projects. Natalie also reports difficulty concentrating, gaining 10 pounds, and sleeping during the day in class.

Furthermore, she states that her friends with whom she previously engaged in a lot of fun activities currently annoy her and have become dull. She reports disliking the cold weather because she is a summer girl and prefers the beach and convertibles. The cold weather limits her from going outside, and she cannot do anything. Natalie states that she dislikes this time of the year because it is dark, grey, and miserable, and the entire city changes with grey and black snow.

Past Psychiatric History:

• General Statement: The client has no relevant psychiatric history.
• Caregivers (if applicable): None
• Hospitalizations: None
• Medication trials: None
• Psychotherapy or Previous Psychiatric Diagnosis: None

Substance Current Use and History: Denies substance use history.

Family Psychiatric/Substance Use History: No family history of substance use or psychiatric disorders.

Psychosocial History: Natalie is single. She recently joined an accelerated high school business program in Chicago, Illinois. She grew up in New Orleans her entire life with both her parents and four brothers. She currently resides in a specialty high school campus dormitory. She is a full-time student and works part-time at a local coffee shop.

Medical History: No chronic illnesses.

• Current Medications: None
• Allergies: None

• Reproductive Hx: No gynecological disorder.

ROS:

• GENERAL: Positive for weight gain and daytime sleepiness. Negative for fever, chills, malaise, or fatigue.
• HEENT: Negative for vision changes, eye pain, blurred/double vision, ear pain, hearing loss, rhinorrhea, or sore throat.
• SKIN: Negative for rashes, bruises, or discolorations.
• CARDIOVASCULAR: Negative for dyspnea, chest pain, palpitations, or edema.
• RESPIRATORY: Negative for breathing difficulties, cough, or wheezing.
• GASTROINTESTINAL: Negative for abdominal pain, nausea/vomiting, or bowel changes.
• GENITOURINARY: Negative for pelvic pain, dysuria, vulvar irritation, or urine color changes.
• NEUROLOGICAL: Negative for dizziness, headaches, muscle weakness, or loss of consciousness.
• MUSCULOSKELETAL: Negative for muscle pain or joint pain/stiffness.
• HEMATOLOGIC: Negative for delayed wound healing.
• LYMPHATICS: Negative for lymph node swelling.
• ENDOCRINOLOGIC: Negative for acute thirst, hunger, polyuria, or heat/cold intolerance.

Objective:

Physical exam:

Vital signs: T 97.4; P-82; R-120; BP-128/84; Ht-5’2”; Wt-192lbs

Diagnostic results: No diagnostic tests were requested.

Assessment:

Mental Status Examination:

Female client in her teenage years. The client is well-groomed and dressed appropriately. She maintains eye contact but appears gloomy. Here the self-reported mood is low, and affect is constricted. Her speech is clear but goes low at times during the interview. She exhibits a logical thought process and has no delusions, hallucinations, or suicidal thoughts. She is oriented and has intact memory and clear judgment.

Differential Diagnoses:

Major Depressive Disorder with Seasonal Pattern (MDD-SP): MDD-SP is diagnosed based on the occurrence and remission of depressive episodes during a specific season of the year. The depressive episodes usually have a seasonal pattern in the past two years (Rai et al., 2021). MDD-