PRAC 6635 Wk 9 Assignment 2: Comprehensive Psychiatric Evaluation and Patient Case Presentation

PRAC 6635 Wk 9 Assignment 2: Comprehensive Psychiatric Evaluation and Patient Case Presentation

S

ubjective:

CC (chief complaint): “I feel sad and hopeless.”

HPI: R.T. is a 26-year-old White female who came to the psychiatric clinic accompanied by her male partner with complaints of feeling sad and hopeless. The feelings began about four weeks after delivering her firstborn son 14 weeks ago. She first thought that the sad feelings were the pregnancy blues that she had seen her sister experience, but her partner got worried when the sadness persisted and worsened over time. The client’s partner mentioned that R.T. has had intense sadness and despair in the past six weeks. She is tearful most of the day and does not find take pleasure in the activities she enjoyed before delivery. The partner also mentioned that the client has uncontrollable worries about her baby’s health and well-being. R.T. reported having sleeping difficulties and usually has frequent nighttime awakening that leaves her feeling tired during the day. She attributes the sleeping difficulties to being frequently woken up by the baby and having to wake up frequently to breastfeed him. Furthermore, she attributed the fatigue to having no one to help her with the baby since her partner is usually working during the day and comes late in the evening. The feelings of sadness have significantly interfered with her ability to function and the client’s partner is concerned that they would risk the health of the mother and infant. The client denies having suicidal ideations or ill feelings toward her baby.

Past Psychiatric History:

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

Substance Current Use and History: The client reported taking whiskeys on weekends and using recreational marijuana before she got pregnant. She has not taken alcohol or used marijuana since she got pregnant.

Family Psychiatric/Substance Use History: She has a maternal aunt who had depression and committed suicide. The maternal grandmother had dementia.

Psychosocial History: R.T. lives with her partner in Rockville MD. She is a hotel supervisor and has a diploma in Hospitality management. She has one son 14 weeks old. The partner is a salesman in an insurance firm.  The client’s support system is her partner and elder sister.

Medical History:

• Current Medications: OTC Tylenol for occasional headaches.
• Allergies: Allergic to Sulfa drugs.

• Reproductive Hx: Para 1+0. No history of gynecologic or obstetric disorders.

Objective:

Diagnostic results: No diagnostic tests were ordered for this patient

Assessment:

Mental Status Examination:

The client is well-groomed and appropriately dressed for the weather and function. She is alert and oriented to person, place, and time. She maintains adequate eye contact. The self-reported mood is sad and the affect is flat. Her speech is clear with normal rate and volume. She demonstrates a coherent, logical, and goal-directed thought process. No obvious delusions, hallucinations, obsessions, phobias, or suicidal ideations. She denies having negative feelings toward the child or thoughts about harming her child. Her long-term and short-term memory is intact. She demonstrates good judgment and insight is present.

Differential Diagnoses:

Postpartum Depression (PPD): PPD is a severe form of depression occurring in a woman in the first few weeks after childbirth. It develops in most cases in the first four months after delivery. It is characterized by sadness and frequent crying, loss of interest in the surrounding; loss of usual emotional response to the family; an intense feeling of unworthiness, guilt, and shame; generalized fatigue, irritability, and difficulty in concentrating; Anorexia and sleep disturbances (Yu et al., 2021). In addition, the woman has a tense irritable appearance, obsessive thoughts; persistent anxiety that makes her feel out of control; and lovingly cares for the infant but not feeling any love or pleasure (Anokye et al., 2018). PPD is the presumptive diagnosis based on the patient’s persistent feelings of sadness and hopelessness that started in the postpartum, sleeping difficulties, and increased fatigue. Besi