Case study : L.T is a 32-year-old black female who resents for psychiatric evaluation due to mood depression.

Assignment

Subjective Section

Chief complainant

The patient starts by saying, “I can’t stop crying, all the time.” The patient complains that since she gave birth to her child two months ago, she has been experiencing mood disorders and difficulties falling asleep even after the baby is already asleep. She complains that especially when the baby cries, she loses her appetite and is not comfortable with her new body shape and size. She says nothing interests her, even writing, which was one of the things she loved before she gave birth. She does not want to contact her friends, and everything seems to be upsetting her.

History of present illness (HPI)

L.T is a 32-year-old black female who resents for psychiatric evaluation due to mood depression. The patient has not been prescribed any psychotropic drugs recently.

Past psychiatric history

The patient has never been examined or treated for any mental disorders in the past. Recently she was hospitalized for a standard childbirth procedure.

Medication trials and current medication

She has not tried any medications in the past, neither is she under any medication currently.

Psychotherapy or previous psychiatric diagnosis

The patient has no history of psychiatric illness and has not been diagnosed or treated with any mental health disorder.

Pertinent substance use, social, and medical history

The patient denies any use of alcohol or cases of drug abuse in the family. Although she says that her uncle was not an opioid abuser, he committed suicide using GSW. She is married and currently lives with her husband with their two kids. She has been working in the retail business for the past five years, but currently, she is a housewife. The patient grew up with her sister together with her both parents. She has been diagnosed with hypertension recently, and she is taking drugs labelled as labetalol 100mg for HTN, which she says that she sometimes forgets to take them. The patient has no legal history or any issues related to violence.

Allergies

L.T is allergic to codeine. She gave birth two months ago, which automatically means that she is lactating. Currently, she is not using any form of contraceptive, and she has had no desire for sex since she gave birth.

ROS

General: No weight loss, fatigue or chills experienced by the patient.

HEET: Her vision is the same no issues of double vision or jaundice. Her ears, nose and throat are okay.

Skin: Her skin has not changed either is she having rashes.

Cardiovascular: No chest discomfort or pains.

Respiratory: She is not coughing or producing sputum, implying her respiratory is fine.

Gastrointestinal: She has eventually lost her appetite and wants to lose weight, although she is not vomiting or feeling abdominal pain.

Genitourinary: The urine colour or odour has not changed, and she is not experiencing any burns during urination. No headaches, no back or joint pains.

Hematologic: No bleeding realized or enlarged nodes.

Endocrinologic: she is not sweating or having any intolerance to heat or cold. No polydipsia.

Objective Section

Physical examination of the documents

Vital signs

T- 97.6 P- 97 R 22 149/98 Ht 5’3 Wt 245lbs

The patient is withdrawn and tearful during the interview.

Diagnosis results

I would order a Genesight psychotropic test. Genesight testing can help determine best treatment options for this patient.

Assessment Section

Examination of mental status

The patient is appropriately dressed and fit for the occasion and the weather. She is conscious of time and place. Her memory is okay, although she appears to be distant during the assessment. Her speech is okay, although she is using a low tone. Her moods are depressed, and she confesses having suicidal thoughts but has not attempted to do so and that she had had no intentions of hurting the baby. No signs of hallucinations or delusions. We can conclude that her critical and insights are okay.

Differential Diagnoses

Postpartum depression is an episode of depression that is common between 4-6 weeks after delivery. It is often characterized by mood disorders, excess anxiety, weight changes, and insomnia (Sadock et al., 2015). Other stressors connected to this depression include inadequate support from family members. Individuals with this kind of depression often feel a lack of interest in some activities and feelings of guilt, suicidal thoughts (Sadock et al., 2015). The client reports signs of this kind of depression as she says she can’t stop crying, she has lost her appetite, has difficulties in sleeping, depressed moods all the time, has no interest in her previous hobbies, and her self-esteem has also gone down (Sherman & Ali, 2018).

Major depressant disorder: this disorder is characterized by depressed moods and a lack of interest in activities with pleasure. It also includes crying all the time, insomnia, loss of weight, feeling hopeless, feeling guilty all the time, lack of energy and even concentration (American Psychiatric Association, 2013). Our client has presented most of these symptoms, which does not mean it is the diagnosis even if the symptoms appeared four weeks after delivery.

Postpartum blues: this disorder is characterized by events of low moods and severe depressive signs. These signs include crying, mood burden, dysphoria, irritability, lack of sleep and concentration (Mullins IV, 2021). The condition primarily affects 30-50% of women who give birth (Sadock et al., 2015). These signs must appear within 2-3days after birth and disappear after two weeks to meet the diagnosis criteria. This is not the case for the patient since the symptoms persisted for more than two weeks.

Reflection

I agree with the preceptor’s assessment and the diagnostic impression of the patient since what the patient is going through is not just ordinary. From this case, I have learned that various mood disorders can have similar symptoms. For example, major depressive disorder and postpartum blues seem to be displaying similar symptoms with postpartum depression. To make the correct diagnosis, one must analyze factors and other stressors associated with the mood disorder (Sadock et al., 2015). I would analyze all the mood disorders to be sure of my final diagnosis for the patient. A legal factor to be considered would be drug safety for both the patient and the baby. Medications pass through breast milk, but the variations of the passage depend on the drugs taken (Frieder et al., 2019)