Identifying Factors: NAME: M. D. AGE: 25 -year-old RACE: HISPANIC MALE. MARITAL

Question

Identifying Factors:

NAME:   M. D. AGE: 25 -year-old RACE:   HISPANIC MALE. MARITAL STATUS: has a girlfriend for 3 months going.   NUMBER OF CHILDREN: none. EMPLOYMENT STATUS: gainfully employed

Chief Complaint: Depression and anger problem.

History of Present Illness: A 25 year old Hispanic male reported to the clinic reporting a long history of mood swings with angry outburst, but lately has been more down, feeling stressed and complain of insomnia. Patient has a history of irritable temperament, and anxiety. Also patient reports occasional agitation, restlessness, poor concentration, passive suicide thoughts, no sense of guilt and amotivation. Also reported difficulty delaying gratification and poor frustration tolerance. He denies suicidal ideation, intent, and plan. He has no family in town. He has a girlfriend for 3 months now. He graduated high school and gainfully employed but have difficulty dealing with his supervisor.

Current Medications: Effexor 75mg/d. but he stopped taking it since a year ago. He takes the Xanax 0.5mg po q 8 hours as needed po for agitation.

Substance Abuse: no history of drug or alcohol addiction

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

1 depression disorder 2.lab_ CSF examination and EEG examination 3 ._ medication _ citalopram 20mg/ daily ,fuoxantne 20mg/daily,sertaline 20mg/ daily initial doses psychosocial therapy _ cognitive behavioral therapy , behavioral therapy and psychotherapy

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