Description
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Post
Julio Noel Baez Perez
10/4/23, 11:53 PM
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Summary of the Clinical Case
The patient visits the office with a headache and fatigue issues. She reports feeling tired and having difficulty getting sleep. She wakes up early and has a dull, aching, and generalized headache. She admits that these symptoms began 21 days ago and have worsened. She has lost interest in the activities she previously enjoyed (Jakobsen et al., 2020). She will not work due to fatigue and a challenge in focusing. She has no appetite and lost weight of 10 pounds last month.
The List of the Client’s Issues
There is a challenge in getting sufficient sleep; she has lost interest in previous activities, lost focus, missed work because of fatigue, is more concerned about her children and fears they might get lost, and have a headache.
Diagnosis to be Considered and Reasons
The potential condition is a major depressive disorder. She presents with six symptoms which have lasted for three weeks. The DSM-5 diagnosis of major depressive disorder requires at least five of the nine symptoms (Westhoff-Bleck et al., 2020). There must be the presence of depressed moods or lost interest in activities. Based on the scenario, the patient has lost interest in an activity, experienced changes in her weight and is not dieting, fatigue, decreased focus, retardation of the psychomotor, and insomnia.
Differential Diagnosis
The potential differential diagnoses are anxiety, bipolar disorder, borderline personality disorder, and adjustment disorder characterized by depressed mood.
Test or the Screening tool to Apply
The Beck Depression Inventory (BID) can screen depression conditions (Westhoff-Beck et al., 2020). It helps measure the behavioral manifestation and the severity of the condition.
Treatment to Propose
The suitable drug for treatment is escitalopram which is an SSRI. It has fewer side effects, well tolerated by the patient with no other medical issues.
The Standard Guideline for the Assessment or Treatment of the Patient
The standard guideline for the assessment and treatment involves the consideration of scientific proof, considering the benefits compared to harms, and the values and preferences of the clients (Jakobsen et al., 2020). There is also a need to consider the applicability of the evidence across demographic groupings and settings.
References
Jakobsen, J. C., Gluud, C., & Kirsch, I. (2020). Should antidepressants be used for major depressive disorder? BMJ Evidence-Based Medicine, 25(4), 130-130.
Westhoff-Bleck, M., Winter, L., Aguirre Davila, L., Herrmann-Lingen, C., Treptau, J., Bauersachs, J., … & Kahl, K. G. (2020). Diagnostic evaluation of the hospital depression scale (HADS) and the Beck depression inventory II (BDI-II) in adults with congenital heart disease using a structured clinical interview: Impact of depression severity. European journal of preventive cardiology, 27(4), 381-390.
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