Chief complaint: “I am experiencing depression and have lost interest in all activities.”
HPI: The patient is a 31-year-old female with a medical history of depression and breast cancer. She was diagnosed with breast cancer approximately one year ago and has been undergoing chemotherapy. The patient reports feelings of depression and has fears of dying from cancer, likely influenced by her mother’s previous experience with cancer. The patient is currently using Trazodone 50 mg on an as-needed basis for sleep.
Mental Status Examination: The patient displays disorientation, agitation, and disorganization. She appears guarded and exhibits a flat affect. The patient’s appearance is consistent with her stated age, and she appears well-groomed. She denies any current thoughts of suicide. The patient demonstrates limited insight into her own problems.
Diagnosis: The patient is diagnosed with Major Depressive Disorder according to DSM-5 criteria (296.23, F32.2).
Plan: The patient’s treatment plan includes initiating Wellbutrin XL at a daily dosage of 150 mg to address her depression. She will also continue using Trazodone 50 mg as needed for sleep. The patient is referred for psychotherapy to address her emotional well-being. She is educated about the potential side effects of the prescribed medication, emphasizing the importance of medication compliance and adherence to the treatment plan. The patient expresses receptiveness to the provided information and demonstrates readiness to comply with the proposed treatment plan. A follow-up appointment is scheduled in two weeks to evaluate the progress of the treatment.
Expert Solution Preview
The patient presents with a chief complaint of experiencing depression and loss of interest in all activities. This is a common symptom of major depressive disorder, and it is important to consider the patient’s medical history and current circumstances in order to formulate an appropriate treatment plan.
The patient is a 31-year-old female with a history of depression and breast cancer. The diagnosis of breast cancer approximately one year ago, along with the ongoing chemotherapy treatment, may have contributed to the development and exacerbation of her depressive symptoms. Additionally, the patient’s fear of dying from cancer, likely influenced by her mother’s previous experience with cancer, could further contribute to her feelings of depression.
During the mental status examination, the patient displayed disorientation, agitation, and disorganization. These findings suggest cognitive impairment and possible psychological distress. The patient also exhibited a flat affect, which is consistent with the depressive symptomatology. It is important to note that the patient denied any current thoughts of suicide. However, limited insight into her own problems was observed, indicating a need for therapeutic intervention.
Based on the DSM-5 criteria, the patient meets the diagnosis of Major Depressive Disorder (296.23, F32.2). This diagnosis takes into account the duration, severity, and associated impairment of the depressive symptoms. It is critical to support the patient in managing her depression, as it can have significant negative impacts on her overall well-being and quality of life.
The treatment plan for this patient includes initiating Wellbutrin XL at a daily dosage of 150 mg to address her depression. Wellbutrin, a medication commonly used for the treatment of depression, can help regulate mood and alleviate depressive symptoms. In addition, the patient will continue using Trazodone 50 mg as needed for sleep. Trazodone is a medication often prescribed for insomnia and may also provide some relief for the patient’s sleep difficulties.
Psychotherapy is an essential component of the patient’s treatment plan, as it aims to address her emotional well-being. Through therapy, the patient can engage in open discussions, gain insight into her depressive symptoms, and develop coping strategies to manage her fears and concerns. Education about the potential side effects of the prescribed medications is crucial, emphasizing the importance of medication compliance and adherence to the treatment plan.
The patient has expressed receptiveness to the provided information and has demonstrated readiness to comply with the proposed treatment plan. A follow-up appointment is scheduled in two weeks to evaluate the progress of the treatment. Regular monitoring and assessment are essential to ensure the effectiveness of the chosen interventions and adjust the treatment plan as needed.
In conclusion, this case highlights the importance of considering the patient’s medical history, current circumstances, and symptomatology when formulating a treatment plan for major depressive disorder. A multidimensional approach, including pharmacotherapy, psychotherapy, and patient education, is recommended to address both the biological and psychological aspects of depression and support the patient on her journey towards emotional well-being.
