Comprehensive Psychiatric Evaluation of a Pediatric Patient with Major Depressive Disorder-Nursing Paper Examples

Patient Initials: G.T. (Patient with Major Depressive Disorder)

Gender: Female

Age: 15

Accompanying Adult: Mother

SUBJECTIVE:

CC: “I do not like my life, and I do not like people as I used to.”

HPI: A 15-year-old Latina patient arrived at the clinic complaining about her recent mood and feelings. The patient reports that she has been perplexed lately by her mood. She is not happy, and the majority of the things she is doing no longer interest her. The client is not exercising as often as she used to because she gets weary fast. She has been relatively quiet the past month. Her sadness and exhaustion make it difficult for her to engage in schoolwork and family activities. She observed that she was no longer as successful or quick at performing regular tasks and domestic chores. The patient reports being easily agitated, distracted, and irritable (Major Depressive Disorder-Nursing Paper Examples).

Due to these issues, she only gets approximately 3–4 hours of sleep daily. She has observed a shift in her appetite and a gradual weight loss. The patient denies having depressive symptoms despite having a bad mood, isolating herself from friends and family, and having decreased activity. She acknowledges feeling more pressured and anxious lately, but an anxiety disorder has not been assessed or diagnosed. Her momentary state has led to several arguments and conflicts with family and friends (Major Depressive Disorder-Nursing Paper Examples).

Social History: G.T. and her parents moved to America from the Caribbean when she was eight. She just turned fifteen. She and her family are currently residing in Texas.

Education and Occupation History: G.T. is in high school.

Substance Current Use and History: The client denies any history of substance abuse.  

Legal History: The client denies any legal history.

Family Psychiatric/Substance Use History: Denied family mental health or substance use issues. Reports father using alcohol on weekends, about three beers daily, Saturday and Sunday (Major Depressive Disorder-Nursing Paper Examples).

Past Psychiatric History:

            Hospitalization: Denies previous hospitalization.

Medication trials: Denies history of medical trials

Psychotherapy or Previous Psychiatric Diagnosis: Denies previous psychiatric evaluation

Medical History: Childhood pneumonia when she was 6.

• Current Medications: Denies current medication.
• Allergies: Reports being allergic to aspirin and developing itchy rashes.
• Reproductive Hx: Not sexually active.  

ROS:  (Major Depressive Disorder-Nursing Paper Examples)

General: States progressive weight loss and occasional feelings of weakness and fatigue. Denies fever.

HEENT: Eyes: Patient denies visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.

Skin: No rash or itching.

Cardiovascular: Denies chest pain, chest pressure, or chest discomfort. No palpitations or edema.

Respiratory: Denies wheezes, shortness of breath, consistent coughs, and breathing difficulties while resting.

Gastrointestinal: The patient reports diet changes and feelings of nausea and vomiting. Denies diarrhea. No abdominal pain or blood. The patient reports experiencing constipation.

Genitourinary: Denies burning on urination, urgency, hesitancy, odor, and odd color.

Neurological: The patient reports frequent headaches and denies dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control. Reports concentration and attention difficulties.

Musculoskeletal: The patient reports occasional muscle pain and weakness. Denies back pain and muscle or joint stiffness.

Hematologic: Denies anemia, bleeding, or bruising.

Lymphatics: Denies enlarged nodes. No history of splenectomy.

Endocrinologic: Denies sweating. No reports of cold or heat intolerance. No polyuria or polydipsia (Major Depressive Disorder-Nursing Paper Examples).

OBJECTIVE:

Vital signs: Stable

Temp: 98.8F

            B.P.: 120/65

            P: 84

             R.R.: 18

             O2: Room air

             Pain: 3/10

             Ht: 5’8 feet

             Wt: 135 lbs

             BMI: 19.6

             BMI Range: Healthy weight

LABS:

Lab findings WNL

Tox screen: Negative

Alcohol: Negative

Physical Exam:

General appearance: The patient appears well-fed and nourished. The patient is well-groomed. The patient addressed the interviewer politely and regularly. She expressed a depressed mood and disappointment with herself. The patient has impaired concentration and attention, impairing clinical assessment (Major Depressive Disorder-Nursing Paper Examples). 

HEENT: Normocephalic and atraumatic. Sclera anicteric, No conjunctival erythema, PERRLA, oropharynx red, moist mucous membranes.

Neck: Supple. No JVD. Trachea midline. No pain, swelling, or palpable nodules.

Heart/Peripheral Vascular: Regular rate and rhythm noted. No murmurs. Consequently, No palpitation. No peripheral edema to palpation bilaterally.

Cardiovascular: The patient’s heartbeat and rhythm are normal. The patient’s heart rate is normal, and capillaries refill within two seconds.

Musculoskeletal: Normal range of motion. Regular muscle mass for age. No signs of swelling or joint deformities. Muscle and back pain rated 3/10.

Respiratory: No wheezes, and respirations are easy and regular.

Neurological: Balance is stable, gait is normal, posture is erect, the tone is good, and speech is clear. The patient has frequent headaches.

Psychiatric: The patient has a depressed mood, irritability, insomnia, and impaired concentration and attention.  

Neuropsychological testing: Social-emotional functioning is impaired.

Behavior/motor activity: Patient behavior was appropriate and constant throughout the assessment

Gait/station: Stable.

Mood: Depressed mood.

Affect: The patient’s mood was depressed.

Thought process/associations: comparatively linear and goal-directed.

Thought content: Thought content was appropriate.

Attitude: the patient was uncooperative at times

Orientation: Oriented to self, place, situation, and general timeframe.

Attention/concentration: Impaired

Insight: Good

Judgment: Good.

Remote memory: Good

Short-term memory: Good

Intellectual /cognitive function: Good

Language: clear speech, with a tone assessed to be normal

Fund of knowledge: Good.

Suicidal ideation: Positive, but no plans.

Homicide ideation: Negative.

ASSESSMENT:

Mental Status Examination:

The 15-year-old female patient complained of feeling down recently when she first came in. She is oriented to self, place, situation, and general timeframe. Her insight, judgment, memory, and fund of knowledge are good, and her speech is clear. The patient claims to get angry easily. Furthermore, The patient was occasionally uncooperative and had trouble focusing during the psychiatric examination.

Hence, made it challenging to build rapport. The patient had a depressing appearance and stated negative beliefs about her life and future, stating she feared not graduating from high school. She admits suicidal ideation but denies active plans. She denies any thoughts of homicide (Major Depressive Disorder-Nursing Paper Examples). 

Differential Diagnosis:

F32.9 Major Depressive Disorder

Depression is marked by apathy and chronic sadness. All depressive disorders have the symptoms of melancholy, emptiness, irritation, and physical and psychological alterations that significantly restrict the patient’s ability to perform daily tasks (Chand et al., 2021). Patients who are depressed have notably lower interest in or excitement for nearly all endeavors for the majority of the day, essentially every day (Major Depressive Disorder-Nursing Paper Examples).

According to the DMS-5 criteria, five of the following symptoms must be present for a diagnosis to be made: difficulty sleeping, loss of interest or pleasure, feelings of inadequacy or helplessness, fatigue or erratic energy, difficulties concentrating or paying attention, fluctuations in appetite or weight, psychomotor issues, suicidality, and depressed mood (Agostino et al., 2021). G.T. exhibits difficulties falling and staying asleep, a loss of interest in once-enjoyable activities like exercise, difficulty focusing and paying attention, changes in appetite and weight, suicidality, and depressed moods, all of which affirm MDD and satisfy the requirement for at least five symptoms outlined in the DSM-5 criteria (Major Depressive Disorder-Nursing Paper Examples).

F40. 10 Social Anxiety Disorder

In social situations, people with MDD usually experience anxiety and worry about what others will think of them. As a result, during an assessment, patients usually disclose their social anxiety concerns. According to a study, 44%–74% of people with social anxiety disorder are diagnosed with major depressive disorder at some point (Langer et al., 2019). According to the DSM-5 criteria, a person must exhibit significant fear or anxiety in one or more social situations where they may be the target of others’ potential observation. The person is worried that their conduct could be misconstrued. Social occasions frequently cause more anxiety or fear than is warranted by the threat they offer (Major Depressive Disorder-Nursing Paper Examples).

Therefore, out of worry or fear, individuals either completely shun them or put up with them. It often lasts no less than six months until the avoidance, dread, or concern seriously hinders or distresses one of the essential domains of functioning. It is irrelevant to compare this fear to the symptoms of another mental disorder or a drug’s side effects. If another medical issue is present, the worry, avoidance, or fear is excessive or unconnected (Rose & Tadi, 2021). Although the patient expresses her worries and fears, she does not show severe anxiety or fear per the criteria for diagnosing SAD; consequently, this diagnosis was disregarded (Major Depressive Disorder-Nursing Paper Examples).

F50. 0 Anorexia Nervosa:

Major depression frequently co-occurs with the eating disorders bulimia nervosa and anorexia nervosa. In this circumstance, anorexia nervosa is more prevalent. Its defining feature is that food intake limitations are comparable to demands, which results in visibly low body weight (Van Eeden et al., 2021). People who suffer from this eating disorder will have a mistaken view of themselves, a fear of gaining weight, and difficulty realizing how severe their condition is. According to Gibson and Mehler (2019), patients have reported irregular menstruation, cold sensitivity, digestive problems, extremity edema, fatigue, and irritability (Major Depressive Disorder-Nursing Paper Examples).

Patients talk about restrictive eating practices such as portion control, self-induced vomiting, and using laxatives or diuretics for purging (Moore & Bokor, 2022). Many people also exercise repeatedly and compulsively. Due to their extended fasting and purging, anorexic patients have many challenges. A patient must show an energy intake restriction compared to needs, leading to substantial weight loss that is less than minimally projected given the patient’s age, sex, developmental trajectory, and physical health, to meet the DMS-5 criteria for anorexia nervosa (Major Depressive Disorder-Nursing Paper Examples).

The patient must admit to having extreme anxiety about gaining weight, behaviors that limit weight increase, or fattening (Moore & Bokor, 2022). Before she became grumpy, according to G.T., she regularly exercised and controlled her diet. She says she has been eating less recently and has a bad appetite. The diagnosis is ruled out because the patient does not practice restrictive dieting but has a poor appetite contributing to losing weight. Additionally, her frame is intact, and she seems well-nourished for an individual with an eating disorder (Major Depressive Disorder-Nursing Paper Examples).   

Reflection:

There is a higher probability that major depressive disease may go untreated or receive incorrect care because it is frequently misdiagnosed and underrecognized. It is challenging to treat MDD patients because they typically lack drive, have little energy, are uncooperative, and are frequently agitated or angry. Due to the significant risk of relapse, treating this illness necessitates commitment from the patient and a strong support system. Most people with MDD deny ever experiencing depressive episodes and instead exhibit low mood, erratic energy and irritable mood. In addition, decreased activity, and disinterest, which makes treating MDD ethically difficult (Major Depressive Disorder-Nursing Paper Examples).

Some specific ethical principles that apply to treating MDD include respect for persons, autonomy, truthfulness, nonmaleficence, nondisclosure, privacy, the need to protect, and beneficence. Yet these viewpoints are weighed and applied differently based on the situation and the degree of MDD. For instance, in cases of severe depression, pain management may be more crucial than promoting patient autonomy. Treatment refusal is challenging while treating MDD because of the low motivation and low energy levels, which frequently clash with the principle of autonomy (Major Depressive Disorder-Nursing Paper Examples).

This experience illuminates the impact MDD has on a patient’s life and reveals how it is connected to eating disorders and social anxiety. It is fundamental to identify the underlying issues, and I would go deeper into the patient’s mental health history if I were given a second chance to work with her. Additionally, I would like the parents to be present to discuss how he thinks about her attitude and behavior and how the atmosphere at home affects the problem(Major Depressive Disorder-Nursing Paper Examples).

Case Formulation and Treatment Plan:

Combining pharmacotherapy and psychotherapy would significantly alleviate symptoms.

Safety Risk/Plan:

The patient says she had suicidal ideation but no active plans. She has no homicidal ideation and does not have any current plans. Despite increased arguments and irritation, the patient is not a threat to other people. Admission is not required (Major Depressive Disorder-Nursing Paper Examples).  

Pharmacological Interventions:

Antidepressants are an effective way to treat major depression and associated symptoms. Selected serotonin reuptake inhibitors like fluoxetine and citalopram should be administered to the patient as the first line of treatment (Agostino et al., 2021). Antidepressants will operate more efficiently with the help of antipsychotics and mood stabilizers to achieve the desired effects of improved mood and increased energy (Major Depressive Disorder-Nursing Paper Examples).

Psychotherapy:

The patient will receive therapy for a few hours every three days for the first three weeks. Examining, analyzing, and reorganizing the family environment’s essential components will be easier with the help of family-based psychotherapy. Cognitive behavioral therapy will increase positive behavior by addressing the negative emotions and feelings that give patients the impression that they are trapped in a negative cycle (Agostino et al., 2021). It will help the practitioner and patient identify challenging circumstances, become aware of their thoughts, feelings, and emotions and any corresponding beliefs, and modify destructive behavioral patterns (Major Depressive Disorder-Nursing Paper Examples).  

Education:

1. Educate the client on medication side effects, potential complications, and the need for medication adherence.
2. Advise the client on the need to follow up with therapy sessions.
3. Regularly evaluate withdrawal symptoms to avoid relapse.
4. Educate the client regarding healthy lifestyle choices.
5. Encourage the client to work with the healthcare team and seek help anytime.  
6. Advise the client to participate in a support group or group therapy to improve social skills.

Consultation/follow-up: Follow-up is in one week for further assessment.

Case Formulation and Treatment Plan:

PRECEPTOR VERIFICATION:

I confirm the patient used for this assignment is a patient who was seen and managed by the student at their Meditrek-approved clinical site during this quarter’s course of learning (Major Depressive Disorder-Nursing Paper Examples).

Preceptor signature: ________________________________________________________

Date: ________________________

References

Agostino, H., Burstein, B., Moubayed, D., Taddeo, D., Grady, R., Vyver, E., … & Coelho, J. S. (2021). Trends in the incidence of new-onset anorexia nervosa and atypical anorexia nervosa among youth during the COVID-19 pandemic in Canada. JAMA Network open, 4(12), e2137395-e2137395.

Chand, S. P., Arif, H., & Kutlenios, R. M. (2021). Depression (Nursing). In: StatPearls [Internet]. StatPearls Publishing.

Gibson, D., & Mehler, P. S. (2019). Anorexia nervosa and the immune system—a narrative review. Journal of clinical medicine, 8(11), 1915.

Langer, J. K., Tonge, N. A., Piccirillo, M., Rodebaugh, T. L., Thompson, R. J., & Gotlib, I. H. (2019). Symptoms of social anxiety disorder and major depressive disorder: A network perspective. Journal of affective disorders, 243, 531–538. https://doi.org/10.1016/j.jad.2018.09.078

Moore, C.A., & Bokor, B.R. (2022). Anorexia Nervosa. In StatPearls [Internet]. StatPearls Publishing.

Rose, G. M., & Tadi, P. (2021). Social anxiety disorder. In StatPearls [Internet]. StatPearls Publishing.

Van Eeden, A. E., van Hoeken, D., & Hoek, H. W. (2021). Incidence, prevalence and mortality of anorexia nervosa and bulimia nervosa. Current opinion in psychiatry, 34(6), 515.