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Subjective:

CC (chief complaint): M.s Liliana ball is reported to be having mood disorder where depression

and stress are the chief complaint.

HPI: Ms. Liliana Ball is aged16, it is reported that she is single and bisexual. Ms. Liliana Ball is

reported to have a history of a treatment since seven years to treat disorder and depression. She

has a been taking sertraline, which has caused irritability, aggression, and impulsivity to her.,Ms.

Liliana Ball has previously been admitted to the teen residential mental health facility for the last

three months and has been discharged with lithium 300mg and 600 at bedtime as well as

aripiprazole 10mg in the morning. During the mental health facility discharge, the patients’ labs

were reported to be at normal range and negative urine toxicology. Additionally, it is reported

that she has hx of domestic violence towards her mother and the two sisters. Ms. Liliana Ball's

grandmother has hx of bipolar while her mother and maternal aunt have anxiety.

Past Psychiatric History:

 General Statement: Ms. Liliana Ball’s treatment for the mood disorder started at the age

of seven.

 Caregivers (if applicable): no caregivers available

 Hospitalizations: according to the patients’ current report, she was hospitalized at the

teen residential mental health facility for three months and discharged with her labs

reading at the normal ranges and urine toxicology being negative. She has hx of self-

harm with cutting.

 Medication trials: sertraline was the previous medication administered to Ms. Ball and

this medication was associated with some effects such irritability, aggression and

impulsivity. At the teen residential mental health facility, lithium 300mg and 600mg and

aripiprazole 10mg were administered to be taken during bedtime and in the morning

respectively. The medication was effective because Ms. Liliana Ball’s labs were normal

during the discharge, and negative urine toxicology recorded. However, the patient

claims that the medication has negatively affected her creative art.

 Psychotherapy or Previous Psychiatric Diagnosis: Previously, Ms. Liliana Ball was taken

to the teen residential mental health facility for psychotherapy. The Psychotherapy was

helpful to the patient helped achieve her labs in the normal range during the discharge

while there is negative urine toxicity.

Substance Current Use and History: she was was positive for cannabis upon admission to the

teen residential mental health facility.

Family Psychiatric/Substance Use History: Ms. Liliana's grandmother have hx bipolar

disorder, while her mother and the maternal aunt have anxiety.

Psychosocial History: Ms. Liliana Ball currently lives with her parents in Tacoma, WA, with

her two young siblings. She is currently in high school. Also, she is currently not partnered.

hobbies: Not indicated

work history: Not yet working or employed since the patient is still a high school student.

legal history: no current legal issues

trauma: she has been fighting disorder and depression since the age of seven

violence Hx: the patient has hx of domestic violence towards her mother and the two young

sisters.

Medical History: she has been under treatment for disorder and depression since the age of 7.

no surgery history although she took sertraline.

Current Medications:

lithium 300mg and 600mg during bedtime

aripiprazole 10mg in the morning

 Allergies: no allergies

 Reproductive Hx: she has been engaging highly in unprotective sex.

ROS:

 GENERAL: no body weakness, weight loss, fever or fatigue.

 HEENT: Eye: the patient does not have visual loss, blurred or double vision. Ear: also,

she has no problem with hearing, sore throat

 SKIN: no skin rash

 CARDIOVASCULAR: no palpitations, chest pain, pressures and discomfort

 RESPIRATORY: no difficulties in breathing, coughing or sputum.

 GASTROINTESTINAL: the patient does not experience the following; vomiting,

diarrhea or anorexia, nor abdominal pain.

 GENITOURINARY: no positive urine taxocolity, urine odor or burn on urination.

 NEUROLOGICAL: the patient has no headache, dizziness, syncope, paralysis, ataxia,

numbness, or tingling in the extremities. No change in bowel or bladder control.

 MUSCULOSKELETAL: no pain in the muscle, back, stiffness or joints

 HEMATOLOGIC: no bleeding, anemia or bruising

 LYMPHATICS: the patient has no history of splenectomy

 ENDOCRINOLOGIC: no sweating, cold or heat intolerance.

Objective:

Physical exam: if applicable

Diagnostic results:
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MRI and ECG tests were carried. The results indicated lack of defect in the patient's heart or

brain functionality. The patient was reported to be suffering from a physiological problem.

However, the patient declined when asked about her depressing and stated today is today and

yesterday was yesterday; it is a matter of mood change.

Assessment:

Mental Status Examination:

The patient does not accept that she undergoing depression. she said that it is a matter of the

change in the mood and thats obvious. the patient’s patients are aware that their child has mental

health issue and depression causing changes in the mood. In regards to her psychological

working and presentation of information, it is evident that she mental issues because she cannot

recognize that she has depression hence her mental state makes her react abnormally. however,

the examination shows that Ms. Lilian Ball has good appetite and social life.

Differential Diagnoses:

Three differential diagnoses derivarable from the patient's mental evaluation include; a

depressive mood accompanied by a mental disorder. The patient realize that she is undergoing

depression and abrunt behavioral change. Although those around her sees her change in behavior

as abig issue, she does not recognize that it is something related to mood disorder she she takes

the changes as normal.

Anxiety disorder
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The patients has an anxiety disorder because she exhibits irritational behavior and attitude

towards routine life's activities (Alavi et al.,2020). She keeps information secretly and hardly

shares the information with others.

Historic personality disorder

The historic personality disorder is the third differential diagnosis for the patient at hand. Reports

states that some family members have been diagnosed with same disorder thus there is a

possibility of having inherited it.

This the most probable disorder is depression and it has negative effects the patient, family

members and the friends because the condition may develop to permanent mental illness.

Reflections:

many people suffering from mental disorders does not recognize their mental well-being just like

Ms. Liliana Ball. they always think that it is normal to have mood change. Therefore, I concur

with the findings of the assessment. In respect to the the mental and legal issues, the patients

information must protected from being accessed by third parties. As a health care provider, it is

important to act in accordance to the ethics and principles guiding the nursing profession by

ensuring that confidentiality is enhanced as well as administering treatments acpables of saving

lives and healing patients (Silva et al., 2018). Additionally, I must engae the patients’ family

,members and friends in discussion such as those involving treatment of action to be undertaken.

Promoting health and effective treatment of the mental health disorders demands adheranced to

physician’s prescription and cunseling to make patients aware that some diseases are normal and
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there is still a chance to live hence issues such as committing suicide are avoided. therefore, my

recommendation is that the family members and friends to offer support and stay with people

suffering from mood related disorders hence making them avoid situations where they might be

thinking of commiting life threatening activities. Counselling also plays crucial role in helping

those suffering from mood disorders recognize themselves (Kazem, 2021).  Therefore, I decided

to refer the patient to the counsellor in her residence where she could get sufficient resourses and

information and get in conduct with the emergency response teams. the resources will help the

patient identify what can positively or negatively affect their mental status. therefore, it is

important to examine the patient’s cultural beliefs and socioecomic status. this information will

help make decisions on the ways to prevent depression and prevent the adverse effects of mental

disorders.
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References

Alavi, S. M., Rafieinia, P., Makvand Hosseini, S., & Sabahi, P. (2020). The Effectiveness of

Unified Trans diagnostic Treatment on Social anxiety symptoms and Difficulty in

Emotion Regulation: Single-Subject Design. Journal of Psychological Studies, 16(2), 7-

24.

Kazem, S. (2021). Exploring the Stigmas Associated with Mood Disorders: Methods of

Decreasing Stigma Within the High School Setting (Doctoral dissertation, Alliant

International University).

Silva, T. N. D., Freire, M. E. M., Vasconcelos, M. F. D., Silva, S. V. D., Silva, W. J. D. C.,

Araújo, P. D. S., & Eloy, A. V. A. (2018). Deontological aspects of the nursing

profession: understanding the code of ethics. Revista brasileira de enfermagem, 71, 3-10.