NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation
CC (chief complaint): Depression and anxiety, challenges with body image, motivation, and social withdrawal.
HPI: Patient reports ongoing struggles with depression and anxiety, recently exacerbated by new job challenges and body image concerns. Initiated therapy and is exploring medication optimization, including genetic testing.
Past Psychiatric History:
- General Statement: History of premenstrual dysphoric disorder, generalized anxiety disorder, OCD unspecified, binge eating disorder, major depressive disorder, recurrent episodes with anxious distress, and ADHD, attentive type.
- Caregivers (if applicable): None.
- Hospitalizations: Outpatient in 2011 at Rockford House in Delaware.
- Medication trials: Past medications include Lexapro, Zoloft, Wellbutrin, Xanax, Adderall, Adderall XR, Propranolol, Silexan. Current medications include Prozac, Adzenys, Hydroxyzine, Wellbutrin XL, Dupixent, Wegovy.
- Psychotherapy or Previous Psychiatric Diagnosis: Ongoing therapy sessions, previously diagnosed with aforementioned disorders.
Substance Current Use and History: Denies drug and alcohol abuse, except for social drinking.
Family Psychiatric/Substance Use History: Father with DM, HTN, hypothyroid; mother with HTN; sister on Lexapro with weight gain.
Psychosocial History: Lives alone. Enjoys activities like working out, gym, yoga, and beach visits. Denies tobacco use, no history of STDs.
Medical History:
- Current Medications: Prozac 40mg, Adzenys 18.8mg, Hydroxyzine 10mg, Wellbutrin XL 150mg, Dupixent, Wegovy, fish oil, Vit D, Zinc with Vit C, MVI.
- Allergies: Cecor, latex.
- Reproductive Hx: Regular menstrual cycles without significant issues.
ROS:
- GENERAL: No appetite or significant weight changes, generally alert.
- HEENT: Normocephalic, no visual or auditory complaints.
- SKIN: Clear, no rashes or lesions.
- CARDIOVASCULAR: Denies chest pain, palpitations.
- RESPIRATORY: Clear breath sounds, no dyspnea.
- GASTROINTESTINAL: Normal bowel habits, no abdominal pain or discomfort.
- GENITOURINARY: No urinary complaints or dysfunctions.
- NEUROLOGICAL: No history of seizures, headaches, or syncope.
- MUSCULOSKELETAL: Full range of motion, no joint pain or swelling.
- HEMATOLOGIC: No history of anemia or bleeding disorders.
- LYMPHATICS: No lymphadenopathy.
- ENDOCRINOLOGIC: History of PCOS.
Physical exam:
- General Appearance: Well-groomed, no acute distress.
- Vital Signs: Within normal limits.
- Neurological: Alert, oriented, cranial nerves intact.
- Cardiovascular: Regular rhythm, no murmurs.
- Respiratory: Clear to auscultation bilaterally.
- Abdominal: Soft, non-tender, no organomegaly.
- Musculoskeletal: Normal strength and tone, no deformities.
Diagnostic results:
- Blood work pending.
- Gene site testing being considered for medication optimization.
Assessment Mental Status Examination: Kempt appearance, alert, cooperative behavior, limited focus, intact memory, low mood, adequate sleep, calm gross motor activity, normal gait, no tremors, oriented, appropriate eye contact, normal rate of speech, congruent affect, logical thought process, no delusions, fair insight and judgment.
Differential Diagnoses:
- F33.1 Major Depressive Disorder, Recurrent Episode, with Anxious Distress: The patient’s ongoing struggles with depression, including feelings of low mood, lack of motivation, social withdrawal, and numbness, align with this diagnosis. The presence of anxiety symptoms alongside depression further supports the specification of “with anxious distress (Marx et al., 2023).
- F41.1 Generalized Anxiety Disorder: The patient’s experiences of anxiety, particularly in the context of new job challenges and body image concerns, suggest this disorder. Symptoms like worry and feeling on edge are characteristic of generalized anxiety disorder (Nilsson et al., 2019).
- F32.81 Premenstrual Dysphoric Disorder (PMDD): Considering the patient’s history of mood and anxiety symptoms potentially correlating with menstrual cycles, PMDD might be a relevant diagnosis. This condition involves more severe emotional and physical symptoms than typical premenstrual syndrome (PMS) (Carlini et al., 2020).
- F42.9 Obsessive-Compulsive Disorder, Unspecified: The patient’s prior diagnosis and potential ongoing symptoms of OCD, although not detailed in the current history, i