mental status examination

In the Assessment section, provide:•  Results of the mental status examination, presented in paragraph form.

•  At least three differentials with supporting evidence. List them from top priority to least priority. Compare the DSM-5-TR diagnostic criteria for each differential diagnosis and explain what DSM-5-TR criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.

1st Diagnostic: Unspecified mood (Affective) Disorder

2nd Diagnostic: Depression Disorder

3rd Diagnostic: Alcohol Use Disorder

•  Read rating descriptions to see the grading standards!

Reflect on this case. Include: Discuss what you learned and what you might do differently. Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), social determinates of health, health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).

The student provides an accurate, clear, and complete diagnostic impression with three (3) differentials. … Reflections are thorough, thoughtful, and demonstrate critical thinking. …Reflections contain all 3 elements from the assignment directions.

mental status examination

Assessment: The patient is a 45-year-old male who presented with symptoms of mood swings, difficulty concentrating, and decreased energy for the past six months. He reports feeling sad, hopeless, and isolated. Mental status examination reveals a flat affect, slowed speech, and a constricted range of affect. The patient appears depressed and withdrawn, but is cooperative and able to provide information. He denies any suicidal or homicidal ideation.

Differential Diagnoses:

  1. Unspecified mood (affective) disorder: The patient meets the diagnostic criteria for an unspecified mood disorder as per the DSM-5-TR. This diagnosis is supported by the presence of depressive symptoms, including a sad mood, decreased interest, and energy, and difficulty concentrating.
  2. Depression disorder: The patient also meets the diagnostic criteria for major depressive disorder. This diagnosis is supported by the presence of five or more depressive symptoms, including sadness, anhedonia, decreased appetite, weight loss, insomnia, psychomotor agitation, and thoughts of worthlessness.
  3. Alcohol use disorder: The patient reports a history of alcohol use, which may be contributing to his depressive symptoms. Alcohol use can cause mood swings and exacerbate depressive symptoms.

The critical-thinking process that led to the primary diagnosis of unspecified mood (affective) disorder was based on the presence of depressive symptoms without meeting the full criteria for major depressive disorder. Pertinent positives include depressed mood, lack of interest, and decreased energy, while pertinent negatives include suicidal or homicidal ideation and psychosis.

Reflection: This case highlights the importance of taking a comprehensive approach to diagnosis, considering multiple differential diagnoses and ruling them out based on evidence. It also highlights the need to consider social determinants of health, such as alcohol use, in the diagnostic process.

In reflection, I learned that it is important to consider patient factors when making a diagnosis, including age, ethnic group, PMH, and risk factors. Additionally, legal and ethical considerations must also be taken into account, such as informed consent, confidentiality, and the duty to report any potential harm to the patient or others.

In terms of what I might do differently, I would prioritize health promotion and disease prevention strategies, including referrals for psychotherapy and substance abuse treatment. I would also prioritize a collaborative approach to care, working with the patient to develop a treatment plan that addresses their specific needs and concerns.

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