Medical Assessment in the Psychiatric Field


  • CC: P. P. perceives medication as not helpful because she feels battered whenever she takes it. Her non-compliance to medicines has been closely linked to a previous depression diagnosis.
  • Past Psychiatric History: According to the psychiatric history of the 26-year-old patient, she has been hospitalized for various conditions, including bipolar disorder, anxiety, and depression. She is currently on depression medication and has a history of attempting suicide in 2017, although she has not made any other attempt since then.
  • Medical History and Current Medication: Miss P.’s medical report also indicates that she uses birth control pills, including hypothyroidism. She has a history of using various drugs, including psychopharmacology, such as Zoloft, which intoxicated her, risperidone for weight gain, and Klonopin for slowing down brain activity. There is no family history of chronic conditions associated with the patient.
  • Allergies: P. does not show any allergic reactions to either food or drugs. She had been addicted to nicotine but quit using alcohol and marijuana during her teen years.
  • Reproductive History: Mrs. P. is sexually active and engages in multiple sexual partners with whom she practices protected sex.
  • Family Psychiatric: Her mother has had almost similar experiences with mental health, reportedly having suffered from bipolar and attempting suicide unsuccessfully. On the other hand, P.’s father may be serving a jail term for handling drugs.

Review of the Systems

  • General: P. P.’s health is stable, with the absence of fever, chills, and body weakness.
  • HEENT: The patient has stable vision and an ordinary sense of hearing. Her nasal system is also sound, and she has a normal throat with no difficulties swallowing.
  • Skin: She generally has dark skin without itchy rashes, ecchymosis, and erythema.
  • Cardiovascular: The absence of chest pains and heart palpitations, and the absence of edema were reported.
  • Respiratory: Stable breathing on exertion and absence of coughing and sputum was reported.
  • Gastrointestinal: Absence of vomiting, nausea, and blood in stool or diarrhea was reported. The patient also notes a lack of appetite when engaged and a strong desire for food when at rest.
  • Genitourinary: No infections on the bladder were reported.
  • Neurological: Normal level of alertness with no complaints of headaches and dizziness was noted.
  • Musculoskeletal: No abnormal muscular conditions or movements were noted.
  • Hematologic: The patient showed no signs of anemia but reported a normal capillary refill.
  • Lymphatics: The lymph nodes were in their standard shapes with no forms of enlargements or inflammations.
  • Endocrinology: No signs of night sweats and polydipsia were reported, with the patient being treated for hypothyroidism.


P. P. is in a stable condition with incredible abilities to make sensible judgments, pay adequate attention, and has a high concentration level. Therefore, it was unnecessary to subject her to laboratory tests. However, the DSM diagnostic model was employed to assess her condition.


Mental Status Test

The patient, P. P., is a female who marches her stated age of 26 years. Her grooming and dress were neat and appropriate, and she answered the interviewer’s questions correctly with clear and coherent statements. Although she occasionally felt irritated by some questions, she demonstrated normal voice and intonation with no signs of abnormalities. Her general attitude toward the questions was appropriate. She claimed her friend perceives her as talkative, although she has no perception disorders. She reported experiencing hallucinations as a teenager and remembered how her friends told her she was talented.

Diagnostic Impression

Bipolar II disorder

The most likely disorder that P. is suffering from is bipolar disorder II. The DSM-5 model indicates patients suffering from this condition have week-episodes of depression and hypomania. During the two episodes, the mood of the patient tends to oscillate. Patients may also portray aggressive behavior and easily get distracted, have signs of euphoria, and show increased determination to achieve their goals (Vieta et al., 2018). Despite having a history of depression, Miss P. has demonstrated most of the symptoms marching bipolar disorder.

Differential Diagnoses

  • Depression: Depression is one of the major mental disorders that affect many people. It involves alternating feelings of low moods and feelings of guilt, hopelessness, and self-worthlessness. Ideation and attempts of suicide characterize it. Other symptoms described by the DSM manual include a lack of interest in previously pleasurable activities (Barberio et al., 2021). The symptoms presented by the patient, in this case, include low mood and over-reactiveness as a result of full energy. However, the impression of depression in this scenario is ruled out because the patient does not portray any signs of suicide attempts or ideation. The patient has also not shown a lack of interest in what was previously pleasurable to her.
  • Hypothyroidism: Various symptoms are associated with hypothyroidism. They include depression, slow processing of thoughts, fatigue, reduced concentration, hypersomnia, unstable moods, psychotic symptoms, and weight gain (Ettleson & Bianco, 2020). However, the symptoms presented by the patients are not adequate to support the impression of this condition.
  • Schizophrenia: Patients with mental conditions portray signs of delusions, hallucinations, incoherent speech, and confusion (Habtewold et al., 2020). However, despite reporting auditory hallucinations, the patient does not present the other symptoms to support the diagnosis of this condition.


The patient needs to be prescribed lithium to restore her mood caused by her bipolar condition. It is also necessary to subject the patient to cognitive-behavior therapy to enable her to change her behavior positively. There is also a need to incorporate social treatments to create a conducive environment that manages the patient’s mood. The patient needs to be rehabilitated to quit using drugs and educated on the need to observe medication according to the prescriptions. Lastly, the recovery program should include a follow-up process to track the patient’s progress. This may involve using a psychiatrist to assess the effectiveness of the treatment.


Barberio, B., Zamani, M., Black, C. J., Savarino, E. V., & Ford, A. C. (2021). Prevalence of symptoms of anxiety and depression in patients with inflammatory bowel disease: A systematic review and meta-analysis. The Lancet Gastroenterology & Hepatology, 6(5), 359-370.

Ettleson, M. D., & Bianco, A. C. (2020). Individualized therapy for hypothyroidism: Is T4 enough for everyone?. The Journal of Clinical Endocrinology & Metabolism, 105(9), e3090-e3104.

Habtewold, T. D., Rodijk, L. H., Liemburg, E. J., Sidorenkov, G., Boezen, H. M., Bruggeman, R., & Alizadeh, B. Z. (2020). A systematic review and narrative synthesis of data-driven studies in schizophrenia symptoms and cognitive deficits. Translational Psychiatry, 10(1), 1-24.

Vieta, E., Berk, M., Schulze, T. G., Carvalho, A. F., Suppes, T., Calabrese, J. R and Grande, I. (2018). Bipolar disorders. Nature Reviews Disease Primers, 4(1), 1-16.

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NursingBird. (2023, July 19). Medical Assessment in the Psychiatric Field. Retrieved from


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Work Cited

"Medical Assessment in the Psychiatric Field." NursingBird, 19 July 2023,


NursingBird. (2023) 'Medical Assessment in the Psychiatric Field'. 19 July.


NursingBird. 2023. "Medical Assessment in the Psychiatric Field." July 19, 2023.

1. NursingBird. "Medical Assessment in the Psychiatric Field." July 19, 2023.


NursingBird. "Medical Assessment in the Psychiatric Field." July 19, 2023.