Assessing and Diagnosing Patients With Mood Disorders. Complete and submit your Comprehensive Psychiatric Evaluation, including your differential diagnosis and critical-thinking process to formulate a primary diagnosis.

 

CC (chief complaint): “I have been having some headache for 6-7 months”.Assessing and Diagnosing Patients With Mood Disorders.

HPI: L.K  is a middle aged male presenting himself in the clinic for an increased headaches for 6-7 months. Previously, the client reports to have been having stomach problems. The patient reports to easily gets annoyed easily by his girlfriend whenever she starts a lot of things. He reports having a noise problem that began in the past six months. More so, the client reports to have been worrying too much whenever his girlfriend drives to an extend of screaming thinking she could cause an accident. Still, the client has been losing interest of any activity happening around him. He also reports of feeling guilty whenever he thinks of being around with his family. Currently, the patient is not subscribed to any psychotic medication. He is refered by ownself to seek medication and treatment in the clinic.Assessing and Diagnosing Patients With Mood Disorders.

Past Psychiatric History: None

Substance Current Use and History: None

Family Psychiatric/Substance Use History: Both parents

Psychosocial History: The patient was born and raised by his parent. The client is the first in a family of two sibling. The other sibling is 17 years and live with the parents. The patient lives with his girlfriend in a house they bought together. Currently, the coulple don’t have a child. Both of them share some of the classes they attend every morning while driving daily. The patient experience fear fearing when his girlfriend is driving thinking she might cause an accident. Currently, the patient gets annoyed out of anything done around him.Assessing and Diagnosing Patients With Mood Disorders.

Medical History:

 

  • Current Medications: None
  • Allergies: No allergies reported
  • Reproductive Hx:

ROS:

  • GENERAL: positive headache; no fever, no chills or sweats, no weight gains of losses of significance
  • HEENT: Reported headache, no visual issues, no running nose, no pain when swallowing, no sore throat, does not use glasses, and no hearing complications.
  • SKIN: No rashes and itchness
  • CARDIOVASCULAR: no palpitations or edema, absence of pressure and chest discomfort.Assessing and Diagnosing Patients With Mood Disorders.

RESPIRATORY:  No running nose. No congestion and breath shortness, no hoarseness.

  • GASTROINTESTINAL: no decreased appetite, no vomiting and nausea, no abdominal pain, no changes in bowel
  • GENITOURINARY: consistent urinary pattern
  • NEUROLOGICAL: no dizziness , no paralysis , +headaches, no abdominal disturbance history, No memory loss patterns;, no change in bowel. No numbness in extremist.
  • MUSCULOSKELETAL: no fracture history, reports no joint pain, no muscle pain and stiffness.
  • HEMATOLOGIC: No anemia, no bleeding, or bruising.
  • LYMPHATICS: -ve throat scratchiness, tender lymph; no bleeding, no history of blood transfusion.
  • ENDOCRINOLOGIC: no report of intolerance case of sweat, cold or heat.Assessing and Diagnosing Patients With Mood Disorders.

Physical exam:

Diagnostics: blood test

Determines the level of GAD antibodies in the blood.

Diagnostic results: 6 units/ml

Assessment

Mental Status Examination: The patient is a middle aged white male and seem to be cooperative and active when interacting with the examiner. He is dressed approprietly, and neatly groomed. The client doe not indicate any evidence of abnormality. He derivers a clear speech in a coherent and in a normal tone. His ideas and thought are subjeted in a logical manner. His face seem to have a calm profile. He denies to have visual hallucination or auditory issue. He claims to have been experiencing a headache during the time of the interview. Cognitively he is oriented as well as alert. His memory of past things is intact and have a good insight.Assessing and Diagnosing Patients With Mood Disorders.

Differential Diagnoses:

Generalized Anxiety Disorder(GAD): GAD illness is characaterised by both the psychological and physical symptoms (Qin et al., 2019). The psychological clinical features include restlessness, tension, difficulty concentrating, being irritable, difficulty controlling feelings of worry and a sense of dread. According to Duijndam & Denol

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