NRNP 6635 week 3 Assignment: Assessing and Diagnosing Patients With Mood Disorders Paper Example Comprehensive Psychiatric Evaluation

Patient Information:

• Name: A.M.
• Age: 34
• Gender: Male
• Race: African-American
• Marital Status: Divorced

Chief Complaint (CC):

“I feel like I’m always in a bad mood, and it’s hard for me to concentrate or enjoy anything. It’s been like this for months.”

History of Present Illness (HPI):

A.M. is a 34-year-old African-American male who presents with complaints of persistent low mood, lack of interest in daily activities, and difficulty concentrating. These symptoms began approximately eight months ago, following his divorce, and have progressively worsened. He reports feeling “exhausted all the time” despite sleeping excessively, yet he continues to wake up feeling fatigued. He mentions that his appetite has decreased, resulting in an unintentional weight loss of about 10 pounds over the past three months. His mood is often irritable, and he finds himself getting easily frustrated with family members and coworkers.

A.M. denies any suicidal ideation or previous suicide attempts but admits to occasional fleeting thoughts of death. He reports that these thoughts are not persistent or distressing enough to act upon. His symptoms have negatively impacted his performance at work, leading to several warnings from his supervisor about his reduced productivity and absenteeism.

He reports no previous history of mood disorders and has never sought psychiatric treatment before. He occasionally uses alcohol to “calm down,” drinking approximately 4–5 drinks per night for the past six months, which began after his divorce.

Past Psychiatric History:

• Previous Diagnosis: None reported.
• Previous Hospitalizations: None.
• Previous Treatments: None.
• Previous Medications: None.

Substance Use History:

• Alcohol: Drinks 4–5 alcoholic beverages per night, daily for the past six months. Denies drinking in the mornings or at work. He has not experienced withdrawal symptoms, but he acknowledges that he drinks to cope with stress and sadness.
• Drugs: Denies the use of illicit drugs or recreational drugs.
• Tobacco: Non-smoker.
• Caffeine: Drinks two cups of coffee daily.

Family Psychiatric/Substance Use History:

• Mother: Diagnosed with Major Depressive Disorder at age 45. Currently on medication.
• Father: No history of psychiatric illness.
• Siblings: Younger brother diagnosed with Generalized Anxiety Disorder.
• Substance Use: No history of substance use disorders in the immediate family.

Social History:

A.M. was born and raised in a middle-class African-American family. He is the eldest of three siblings and maintains a good relationship with them, although he is currently estranged from his ex-wife. He has a 7-year-old daughter from his marriage and shares custody with his ex-wife. A.M. completed college and has been working as a sales manager at a tech company for the past five years.

His divorce, finalized eight months ago, was contentious, and he describes the relationship as “emotionally draining.” He currently lives alone in an apartment and has limited social interactions outside of work and co-parenting responsibilities. He reports that he stopped engaging in his hobbies, such as playing basketball and attending social events, around the same time his symptoms began.

A.M. has no legal issues or history of trauma. He denies any history of physical or emotional abuse.

Medical History:

• Current Medical Conditions: Mild hypertension, managed with a low-sodium diet. No medications.
• Past Medical Conditions: None significant.
• Surgical History: None.
• Chronic Illnesses: None.
• Allergies: No known drug allergies.

Review of Systems (ROS):

• General: Reports feeling fatigued and weak. Unintentional weight loss of 10 pounds in the last three months.
• Cardiovascular: No chest pain, palpitations, or shortness of breath.
• Respiratory: No cough or difficulty breathing.
• Gastrointestinal: Reduced appetite; no nausea or vomiting.
• Neurological: No headaches, dizziness, or seizures.
• Musculoskeletal: No joint or muscle pain.
• Endocrine: No changes in temperature tolerance, no excessive thirst or urination.
• Psychiatric: Persistent low mood, loss of interest in previously enjoyable activities, feelings of worthlessness, irritability, concentration difficulties, occasional though