Depression & Anxiety Case Study

Depression & Anxiety Case Study

Instructions

Complete a full intake on this patient and then develop a treatment plan using the template offered.

Patient History

The patient is a 59-year-old married woman with 5 grown children

She is moderately overweight (BMI 30) and was diagnosed with non-insulin-dependent diabetes 10 years ago; she is fairly well managed on an oral hypoglycemic medication (glipizide 10 mg twice per day)

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Two years ago, the patient experienced 2 tremendous stressors: her oldest child developed leukemia (now in remission), and her mother and father both passed away Depression & Anxiety Case Study

She suffered a significant and impairing major depressive episode that went untreated until recently

This was her fifth episode of depression; she experienced 2 major depressive episodes as a teenager, and she developed postpartum depression and anxiety following the births of 2 of her children

Four months ago, after she was too fatigued to get out of bed, she sought treatment for the first time in her life

After receiving education and support from her clinician, she reluctantly agreed to take Paxil 30 mg/day

The patient has experienced a near-complete resolution of her symptoms in the last 6 months; however, she has developed side effects and wants to discontinue the medication

Specifically, she has increased appetite and has correspondingly gained 7 pounds in the last 4 months, with an increase in HgA1c of 1 full percentage point

She also reports excess daytime sedation and anorgasmia (very unusual for her)

What options can you offer to manage these side effects? Be specific

What education should you give the patient about stopping this medication abruptly?

What is your treatment plan? Depression & Anxiety Case Study

Assignment File(s)

· Case Study TemplatePreview the documentInitial Psychiatric SOAP Note Template

There are different ways in which to complete a Psychiatric SOAP (Subjective, Objective, Assessment, and Plan) Note. This is a template that is meant to guide you as you continue to develop your style of SOAP in the psychiatric practice setting.

Criteria

Clinical Notes

Informed Consent

Informed consent given to patient about psychiatric interview process and psychiatric/psychotherapy treatment. Verbal and Written consent obtained. Patient has the ability/capacity to respond and appears to understand the risk, benefits, and (Will review additional consent during treatment plan discussion) Depression & Anxiety Case Study

Subjective

Verify Patient

Name:

DOB:

Minor:

Accompanied by:

Demographic:

Gender Identifier Note:

CC:

HPI:

Pertinent history in record and from patient: X

During assessment: Patient describes their mood as X and indicated it has gotten worse in TIME.

Patient self-esteem appears fair, no reported feelings of excessive guilt,

no reported anhedonia, does not report sleep disturbance, does not report change in appetite, does not report libido disturbances, does not report change in energy,

no reported changes in concentration or memory.

Patient does not report increased activity, agitation, risk-taking behaviors, pressured speech, or euphoria. Patient does not report excessive fears, worries or panic attacks. Depression & Anxiety Case Study

Patient does not report hallucinations, delusions, obsessions or compulsions. Patient’s activity level, attention and concentration were observed to be within normal limits. Patient does not report symptoms of eating disorder. There is no recent weight loss or gain. Patient does not report symptoms of a characterological nature. Depression & Anxiety Case Study