| Subjective | Objective |
| The patient is a 29-year-old, Latinosingle male referred by his primary care provider for a psychiatric evaluation at an outpatient clinic.
Patient’s Chief Complaints: “I think I might be depressed.”
History of Present Illness The patient reports increasingly depressive symptoms with onset 5 months ago. He is experiencing stress related to being unemployed, financial strain and needing to sell his home because he cannot afford the mortgage. He reports depressed mood, low energy, low motivation, anhedonia, poor concentration, loneliness, low self-esteem, hopelessness, and decreased appetite with 2 to 3 lb. weight loss over the past month. He reports difficulty falling and staying asleep due to anxiety and restlessness, difficulty making decisions and self-isolation. He endorses anxiety related to the stressors reported above, as manifested by restlessness, worry, and muscle tension. He reports that his current mental state is impeding his ability to apply for new employment. Past psychiatric history: no previous history, this is the client’s first contact with a mental health provider. Past Medical History: childhood asthma, does not use inhaler. Family History · Father is alive and well. · Mother is alive, has anxiety · One brother age24, alive and well Social History · Lives alone · single · does not have any friends · alcohol use 1-2 times/week. · no marijuana or illicit drug use · attended one year of college. Trauma history: Patient was bullied in middle school due to his difficulty learning English.No nightmares or flashbacks. Review of Systems · appetite diminished, weight loss 2-3 lbs · sleeps 5-7 hours at night, difficulty falling asleep with frequent night waking. Allergies: NKDA,allergic to shellfish, grass, perennial trees, dust mites, and cockroaches. |
Physical Examination:
Height: 67″, weight: 180 lb. General: Well-nourished male appears stated age Mental status exam: Appearance: appropriate dress for age and situation, well nourished, eye contact poor, slumped posture Alertness and Orientation: alert, fully oriented to person‚ place‚ time‚ and situation, Behavior: cooperative Speech: soft, flat Mood: depressed Affect: constricted, congruent with stated mood Thought Process: logical‚ linear Thought content: Self-defeating thoughts, endorses thoughts suggestive of low self-worth. No thoughts of suicide‚ self-harm‚ or passive death wish Perceptions: No evidence of psychosis, not responding to internal stimuli, reports auditory hallucinations. Memory: Recent and remote WNL Judgement/Insight: Insight is fair, Judgement is fair Attention and observed intellectual functioning: Attention intact for purpose of assessment. Able to follow questioning. Fund of knowledge: Good general fund of knowledge and vocabulary Musculoskeletal: normal gait |
Primary diagnosis: Major Depressive Disorder, single episode, moderate with anxious distress (F32.1)
Application of Course
- Select one drug to treat the diagnosis(es) or symptoms.
- List medication class and mechanism of action for the chosen medication.
- Write the prescription in prescription format.
- Provide an evidence-based rationale for the selected medication using at least one scholarly reference. Textbooks may be used for additional references but are not the primary reference.
- List any side effects or adverse effects associated with the medication.
- Include any required diagnostic testing. State the time frame for this testing (testing is before medication initiation or q 3 months, etc.). Include normal results range for any listed laboratory tests.
- Provide a minimum of three appropriate medication-related teaching points for the client and/or family.
2. Integration of Evidence: The student post provides support from a minimum of one scholarly in-text citation in addition to the textbook.
Solution:
Select one drug to treat the diagnosis (es) or symptoms
The assigned patient is a29-year-old, Latino single male who has been diagnosed with Major Depressive Disorder, single episode, moderate with anxious distress. From the case, patient aspectsthat depictanxious distress include restlessness, worry, and muscle tension. In light of this, one of the drugs that can be used to treat the diagnoses above is fluoxetine.