PRAC 6645 WEEK 4 Comprehensive Psychiatric Evaluation Note and Patient Case Presentation, Part 1 Subjective:

PRAC 6645 WEEK 4 Comprehensive Psychiatric Evaluation Note and Patient Case Presentation, Part 1

Subjective:

CC (chief complaint): “I have been diagnosed with MDD, GAD, PTSD, DID, and ADHD related to Bipolar.”

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HPI: A.A is a 28-year-old female who presented with reports that she has been diagnosed with MDD, GAD, PTSD, DID, and ADHD related to Bipolar. She reports that she has been admitted 3-4 times because of depression. She was last hospitalized on 18th September 2022 after accidentally overdosing on cocaine and was raped when she overdosed. She mentions that she had been sober for five months from alcohol and cocaine. However, she had a relapse in February 2024. She reports that her former therapist, Elizabeth, was the best therapist she ever encountered since she taught her about magical thinking. The patient lost her private insurance and now needs a new therapist. She states that a year ago, she visited an EMDR therapist but did not have therapy with the therapist. The patient reports wanting to attend individual therapy and be referred for medical evaluation.

Past Psychiatric History:

• General Statement: History of MDD, GAD, PTSD, DID, ADHD, alcohol use disorder, and cocaine use.
• Caregivers (if applicable): None
• Hospitalizations: 3-4 times for depression; Last admission was 18th September 2022 due to a Cocaine overdose.
• Medication trials: None
• Psychotherapy or Previous Psychiatric Diagnosis: MDD, GAD, PTSD, DID, ADHD, alcohol use disorder, and cocaine use

Substance Current Use and History: Positive history of alcohol use disorder and cocaine use. She admits to smoking cigarettes and vaping.

Family Psychiatric/Substance Use History: The patient’s 24-year-old sister was sexually and physically abused by their stepfather at the age of 5-10 years.

Psychosocial History: The patient has a daughter and states she gets along with her daughter’s father, Kevin, although they are not together. However, she states that Kevin can be verbally abusive. She reports that she has no current significant other. She states that she loves being a mother to her daughter. She mentions that she remembers minimal about her childhood, probably due to trauma. The patient’s father and mother have a poor relationship.

Medical History: Positive for Thyroid problem; Reports sleep apnea.

• Current Medications: None
• Allergies: None

• Reproductive Hx: Para 1+0

Objective:

Diagnostic results: No tests were administered.

Assessment:

Mental Status Examination:

The patient is oriented to person, place, and time. The self-reported mood is anxious, and affect is constricted. Her speech is clear and goal-directed. She has a coherent thought process. No evident hallucinations or delusions. She denies current suicidal or homicidal ideations. She has good short and long-tem memory. She demonstrates good abstract thought and judgment. Insight is present.

Differential Diagnoses:

1. F33. 2 Major Depressive Disorder (MDD), recurrent severe, without psychotic features Persons with MDD present with a sad or depressed mood or a lack of interest in activities. They often exhibit signs of inattention, fatigue, loss of energy, concentration difficulties, and appetite disturbance (Christensen et al., 2020). MDD was chosen because the patient has a history of depression.
2. F41.1 Generalized Anxiety Disorder (GAD): Adults with GAD often exhibit hyperactive behavior, like fidgeting and inattentive behaviors. These behaviors are usually accompanied by persistent fear and worries and somatic symptoms of anxiety (Mishra & Varma, 2023). The patient has a history of GAD and the reported mood is anxious, making this a differential diagnosis.
3. F90. 2 Attention-deficit/hyperactivity disorder (ADHD), Combined type: The clinical manifestation of ADHD in adults includes difficulty getting started on tasks, variable attention to detail, difficulties with self-organization and prioritization, and poor pe