Read the following information to answer questions below regarding medication you chose to treat the Primary diagnosis: Major Depressive Disorder, single episode, moderate with anxious distress (F32.1)
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)
1. Select one psych drug to treat the primary diagnosis from above based on the scenario for- Major depressive disorder, single episode, moderate with anxious distress.
2. List medication class and mechanism of action for the psych drug chosen medication.
3. Write the prescription in prescription format.
4. Provide an evidence-based rationale for the selected medication using at least three scholarly references.
5. List any side effects or adverse effects associated with the medication you choose.
6. 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.
1. Provide a minimum of three appropriate medication-related teaching points for the client and/or family. Cite a scholarly source. Accurately analyze, synthesize, and/or apply principles from evidence.