Identifying Factors: NAME: D J AGE: 27-year-old. RACE: African American. Marital

Question

Identifying Factors:

NAME:   D J AGE: 27-year-old. RACE: African American. Marital status: Married.   NUMBER OF CHILDREN: none. . EMPLOYMENT STATUS: work as sales clerk with a high school degree.

Chief Complaint: I don’t get along well with my Boss

History of Present Illness: A 27 year old female came to the clinic complaining of not able to take and follow through with instruction which makes her constantly have problem with her boss at work.

Onset of psychiatric problem was at age 15, when she was first diagnosed with ADHD and was treated with Adderall for sometimes; since then she has been hospitalized multiple times, diagnosed and treated for alternating agitation and depression. She is currently presented with depression. She denies suicidal ideation, reported loss of energy, inability to think, no interest in activities and problem following instruction.

S/S: during assessment patient was noted to easily distracted, disorganized and have thought blocking. She came into the clinic with her husband who is very supportive.

Current Medications: she has been treated in the past with Lexapro 30mg/dl but patient stopped taking the medication about a month ago stating the medication is not helping her.

Substance Abuse: No history of substance abuse reported

Family History: father was diagnosed of bipolar disorder and mother has problem with anxiety not diagnosed

Other information you might want?

Clinical Impressions: (Rationale for diagnosis and recommendations for services)

DSM-5 Diagnosis:                                      

Recommendations:

Labs:

Psychiatric Medications:                                                                                                                                                                     

Drug:                                         Dose/Schedule:                          Number/Refill:                                     Fact Sheet Given     Other

Rationale for each recommendation

Teaching

What would you include in a biopsychosocial treatment plan for the patient in addition to pharmacotherapy?

Explanation / Answer

Depression disorder with gendar dysphoria. Lab._csf examination and EEG examination. Medication _ mood stabilizer plus antidepressant like _ mood stabilizer _ lithium , Lamotrigine, olanzapine antidepressant _ citalopram 20 mg / daily initial dose,fluoxetine 20mg/ daily ,sertraline 20 mg/ daily. Psychosocial therapy _ 1 cognitive behavioural therapy,2 _ behavioural therapy,3 _ psychotherapy etc.

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