The client is a 25-year-old

Posted: April 4th, 2019

Subjective Objective
The client is a 25-year-old, Latino male referred by his primary care provider for a psychiatric evaluation at an outpatient clinic.
Client’s Chief Complaints:
“I think I might be depressed.”

History of Present Illness
The client reports increasing depressive symptoms with onset three months ago. He is experiencing stress related to unemployment, financial strain, and needing to sell his home quickly 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 12 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 stress related to the abovementioned stressors, as manifested by restlessness, worry, and muscle tension. He reports that his current mental state is impeding his ability to apply for new employment and prepare his home for the impending sale.
Past psychiatric history: no previous history; this is the client’s first contact with a mental health provider.
Past Medical History: none
Family History
• Father is alive and well.
• Mother is alive, has had depression “all her life”
• One brother, age 18, 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: Client reports was bullied in middle school due to his poor grasp of the English language at that time. No reports of nightmares or flashbacks.
Review of Systems
• appetite diminished, weight loss 15 lbs
• sleeps 5-6 hours at night, difficulty falling asleep with frequent night waking.
• No headache
• No palpitations, tremors
Allergies: NKDA, allergic to grass, perennial trees, dust mites, and cockroaches. Physical Examination:
Height: 65″, weight: 205 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.
Memory: Recent and remote WNL
Judgement/Insight: Insight is fair, Judgement is fair
Attention and observed intellectual functioning: Attention intact for the 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)

NR546 Wk5 case study. General Directions

Must be in APA format with at least 3 scholarly articles within the past 5 years.

Review the provided case study to complete this week’s discussion.

Include the following sections:

Application of Course Knowledge: Answer all questions/criteria with explanations and detail.
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.). Includes normal results range for any listed laboratory tests.
Provide a minimum of three appropriate medication-related teaching points for the client and/or family.
Integration of Evidence: Integrate relevant scholarly sources as defined by program expectations:
Cite a scholarly source in the initial post.
Cite a scholarly source in one faculty response post.
Cite a scholarly source in one peer post.
Accurately analyze, synthesize, and/or apply principles from evidence with no more than one short quote (15 words or less) for the week.
Include a minimum of two different scholarly sources per week. Cite all references and provide references for all citations.
Engagement in Meaningful Dialogue: Engage peers and faculty by asking questions, and offering new insights, applications, perspectives, information, or implications for practice.
Peer Response: Respond to at least one peer on a topic other than the initially assigned topic.
Faculty Response: Respond to at least one faculty post.
Communicate using respectful, collegial language and terminology appropriate to advanced nursing practice.
Professionalism in Communication: Communicate with minimal errors in English grammar, spelling, syntax, and punctuation.
Reference Citation: Use current APA format to format citations and references and is free of errors.
Wednesday Participation Requirement: Provide a substantive response to the graded discussion topic (not a response to a peer or faculty), by Wednesday, 11:59 p.m. MT of each week.
Total Participation Requirement: Provide at least three substantive posts (one to the initial question or topic, one to a student peer, and one to a faculty question) on two different days during the week.

Application of Course Knowledge:

In this case study, we are presented with a 25-year-old Latino male who has been referred for a psychiatric evaluation due to presenting symptoms indicative of depression. His chief complaint is his self-identified possibility of being depressed. The client’s history of present illness reveals that he has been experiencing increasing depressive symptoms over the past three months, which are closely associated with stressors such as unemployment, financial strain, and the need to quickly sell his home due to inability to afford the mortgage.

His symptoms include a depressed mood, low energy, anhedonia, poor concentration, loneliness, low self-esteem, hopelessness, and weight loss. The client also reports difficulties with sleep onset and maintenance, anxiety, restlessness, difficulty making decisions, and self-isolation. These symptoms are significantly impeding his ability to seek new employment and prepare his home for sale.

Past psychiatric history indicates that this is the client’s first contact with a mental health provider. Past Medical History is unremarkable. Family History includes a mother with a lifelong history of depression. The client’s Social History is marked by living alone, being single, and not having any friends. He consumes alcohol occasionally but does not use marijuana or illicit drugs. He has completed one year of college education. The client’s Trauma History reveals that he was bullied during middle school due to language difficulties, but there are no reports of nightmares or flashbacks.

The Review of Systems indicates diminished appetite and weight loss, sleep difficulties, but no reports of headaches or palpitations. The client has allergies to certain allergens but is not on any medication for them.

Physical Examination details the client’s height, weight, and general appearance. The Mental Status Exam notes his appearance, alertness, behavior, speech, mood, affect, thought process, thought content, perceptions, memory, judgment/insight, attention, and intellectual functioning. His musculoskeletal system is noted as normal. The Primary Diagnosis given is Major Depressive Disorder, single episode, moderate with anxious distress (F32.1).

Integration of Evidence:

In selecting a medication for the diagnosis, one might consider antidepressant therapy. A possible medication could be a selective serotonin reuptake inhibitor (SSRI), such as sertraline. This class of medication increases the availability of serotonin in the brain, which is often reduced in individuals with depression. A prescription for sertraline might look like this:

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Prescription: Sertraline 50 mg orally once daily in the morning.
An evidence-based rationale for this choice can be supported by the work of Cipriani et al. (2018) in a comprehensive meta-analysis that demonstrated the efficacy of sertraline and other SSRIs in treating major depressive disorder. Common side effects associated with sertraline include nausea, insomnia, and sexual dysfunction (APA, 2017).

Diagnostic testing, in this case, could involve baseline laboratory tests, including complete blood count (CBC) and basic metabolic panel (BMP), to ensure that there are no underlying medical conditions contributing to the depressive symptoms. These tests should be conducted before medication initiation.

Medication-related teaching points could include:

Dosage and Timing: Instruct the client to take the medication as prescribed and at the same time every day to ensure consistent levels in the bloodstream.

Side Effects: Discuss potential side effects like nausea and sexual dysfunction, emphasizing that they are usually temporary and may subside over time.

Compliance: Highlight the importance of continuing the medication even if improvements are not immediately noticeable, as antidepressants often take several weeks to show their full effects.

Engagement in Meaningful Dialogue:

In responding to peers and faculty, we can offer insights into the consideration of psychotherapy in conjunction with pharmacological treatment. Additionally, discussing the importance of monitoring for potential side effects and addressing any concerns the client may have about the medication can contribute to a fruitful dialogue.

Professionalism in Communication:

Maintaining respectful and professional communication is vital in healthcare interactions. Clear and concise language helps ensure that information is effectively conveyed and understood.

Reference Citation:

American Psychiatric Association. (2017). Practice guideline for the treatment of patients with major depressive disorder. American Psychiatric Association.

Cipriani, A., Furukawa, T. A., Salanti, G., Chaimani, A., Atkinson, L. Z., Ogawa, Y., … & Geddes, J. R. (2018). Comparative efficacy and acceptability of 21 antidepressant drugs for the acute treatment of adults with major depressive disorder: a systematic review and network meta-analysis. The Lancet, 391(10128), 1357-1366.