Final Case Formulation: Evaluation and Management of Depressive Clinical Manifestations

Final Case Formulation Paper
Student's Name
College/University
Course
Professor's Name
Due Date
Formulation of the Case Study
The case scenario constitutes a comprehensive assessment of a 14-year-old female patient who was referred to the psychiatric unit for evaluation and management of depressive clinical manifestations at the age of seven. The patient is of African American descent, currently in grade eight, and living in a small city with his parents and siblings.
Subjective
The adolescent reported some clinical manifestations, including anxiety and depressive symptoms. Regarding depressive symptoms, the symptoms will be described or reported in this section. The adolescent kept crying frequently and demonstrated excessive worry when the parents were away during weekdays. She also shows some fatigue episodes because she lacks energy, is tired, and is exhausted. The patient also struggles with feelings of worthlessness as she does not exert significant effort to interact with her siblings and peers. She has trouble thinking, as evidenced by constantly waking up at night. Disturbed sleep is a recorded symptom in the adolescent. Regarding anxiety symptoms, the adolescent feels apprehensive and confused. Confusion could be emanating from increased anxiety. In some instances, the patient reported a racing heart despite not engaging in physical activity. The child also has shortness of breath, which could be attributed to anxiety. In addition, the patient frequently demonstrates avoidance because of the rising anxiety levels.
Boland et al. (2021) indicate that it is also crucial to consider the current stressors for the patient. She has serious problems interacting with other children in the classroom. Her emotional state is significantly affecting her studies. Personality conflicts in school are being reported. The patient's schooling problems have resulted in disciplinary action from the teachers. She is experiencing significant relationship strife. The patient has recently experienced separation from her father, who went abroad for work. In addition, significant social issues are reported in adolescents, primarily due to a lack of effective interactions with other children in the neighborhood. It is apparent that the adolescent's emotional state is significantly affecting her social life and ability to maintain effective relationships.
Despite recording deterioration in appetite, the adolescent has not recorded any significant weight loss. There are no gastrointestinal issues recorded. In addition, there are musculoskeletal pains reported in the patient. The patient is not allergic to any medications. This implies that any approved medication can be administered through any route to achieve better health outcomes. The patient did not report surgical history within the previous year. The family has a history of mental health illness as her veteran grandfather struggled with post-traumatic stress disorder. There is no history of mental health in the immediate family.
Objective
Regarding depressive symptoms, the adolescent recorded a lack of concentration in the classroom as well as in home environments. She appears gloomy and withdrawn. The patient is tearful during the session and demonstrates problems thinking. In addition, the patient is expressing a sense of worthlessness. However, she denied suicidal ideation. Regarding anxiety manifestations, the patient is visibly anxious and apprehensive. She is avoidant and confused, which could be attributed to the observed anxiety. Accordingly, the patient recorded shortness of breath and changes in breathing patterns occasionally. She is visibly sweating on her face and hands. The patient fainted during the session.
Regarding behavior, the mother noted that she took her medication regularly. The patient's self-care skills have significantly dropped as she pays little attention to grooming and looking neat. The teen kept complaining about muscle cramps and tension, headaches, pain in the back, discomforts, and fatigue, although these could be linked to pubertal alterations. She also demonstrates less socialization with friends and family members. The adolescent was also shy and kept avoiding direct eye contact. Functioning during school is also challenged or impaired. However, the patient's anger is well-managed and controlled. The patient rarely demonstrates impulsive behaviors, but some are still transpiring. The patient's water and food intake has been reduced, and she appears to have lost her appetite in the recent past. She is confused sometimes. Sleep problems are also well-established. The patient experiences problems falling asleep and keeps waking up the entire night. She also reports waking up early.
A Full Physical Assessment
The patient's general appearance can be termed as averagely groomed, well-nourished, and in no distress. The patient's mood and affect appeared problematic. The skin turgor is good, and no prominent lesions or unusual bruising. The hair texture and distribution are normal. The color of the nails is normal, and no deformities are recorded. There are no visible masses, scarring, or depressions recorded. The eyes' visual acuity is intact, the conjunctiva is clear, and no hemorrhages or exudates. The ears appear normal, and the hearing is intact. The nose has no external lesions, the mucosa is non-inflamed, and the turbinate and septum are normal. The mouth mucous membranes are moist, and no mucosal lesions are present. No evident periodontal disease or caries was recorded. There was no significant resorption, and gingival inflammation was recorded. The pharynx mucosa is non-inflamed, and no exudate or tonsillar hypertrophy is present. Accordingly, the neck does not have lesions, supple, adenopathy, or bruits.
The assessment of the heart does not show any thrills or cardiomegaly. The heartbeat has a regular rhythm and rate. There is no percussion, and auscultation is lungs. Regarding the abdomen, bowel sounds are normal, with no organomegaly, hernia, tenderness, or masses. The spine is without any deformity. The rectal system is normal. Regarding extremities, no deformities or amputations, varicosities or edema, and peripheral pulses are intact. The musculoskeletal system demonstrates normal station and gait. The pelvic area is normal. Breasts are normal, and no nipple abnormalities or masses were noted.
Assessment
It is necessary to consider the patient's mental status by conducting an exam of the same (Boland et al., 2021). The patient presents as distracted, anxious, disheveled, and sad. The patient also shows signs and symptoms of moderate depression. Demeanor is, to a greater extent, sad and thought content could be termed depression. The adolescent's effect is viable to verbal content. Her associations are significantly intact. The patient did not demonstrate any signs of psychotic manifestations during the session. Suicide ideation was denied. Homicidal intentions and ideas were denied. The fund of knowledge and cognitive functioning are age appropriate and intact. The long and short-term memory is significantly intact, as is the capacity to do arithmetic calculations and abstract. The adolescent is completely oriented. The fund of knowledge and vocabulary indicates that her cognitive functioning is within the average range. The patient also demonstrates honest insight into issues. In addition, her judgment appears intact and normal. There are various manifestations of anxiety. The patient is easily distracted by occurrences in the immediate environment. The adolescent demonstrates problems maintaining constant eye contact during the session.
Rating Scales
Some rating scales will be used in this assessment. The General Anxiety Disorder 7-item scale constitutes one of the tools that will be utilized to screen the patient for anxiety or measure the severity of the mental health illness. The assessment tool is not tailored to offer a diagnosis; thus, only trained medical professionals can employ it. The General Anxiety Disorder 7-item scale refers to a self-administered screen and questionnaire that can be employed to identify and establish the severity of General Anxiety Disorder in adolescents (Sun et al., 2021). The General Anxiety Disorder 7-item is obtained by summing scores for the respective questions in the scale (total points). When screening the patient for anxiety disorders, a score of eight or above represents a reasonable cut-off point for detecting possible cases of generalized anxiety disorder. In this context, an additional diagnostic evaluation is necessary to determine the presence as well as the kind of anxiety disorder. Applying the cut-off point of 8, the General Anxiety Disorder 7-item scale comprises a sensitivity of 92 percent as well as a specificity of 76 percent for the diagnosis of generalized anxiety disorder. The cut-off correlates with the anxiety severity level, including scores 0-4 (minimal anxiety), scores 5-9 (mild anxiety), scores 10-14 (moderate anxiety), and scores above 15 (severe anxiety). Grounded on contemporary meta-analyses, mental health professionals and experts recommend considering a cut-off point of eight to optimize the scale's sensitivity without undermining its specificity (National HIV Curriculum, 2023). The patient obtained an outcome bet...