Assessment For Patient Complaining Of Depression Assignment
Assessment For Patient Complaining Of Depression Assignment
7/18/22 the patient reported to the facility with a major complaint of depression which started at the age of nine and remained untreated for a year when he started talking Zoloft as an antipsychotic drug. According to the step dad, at the age of nine, the patient was sexually abused and he was bullied while in school. At some point, the patient took his Ambien to herm himself. To date, the patient takes Zoloft 10mg po daily to ease his symptoms and the drug is helping to some extent. In the past, at the age of nine, the patient was diagnosed with depression after he was bullied at school and was sexually abused. Depression is a major symptom of major depressive disorder (Benazzi, 2022)Assessment For Patient Complaining Of Depression Assignment. The patient does not smoke nor drink and lives with his mother and step dad. The diagnosis for the patient is Moderate major depressive disorder, recurrent episode. Some of the signs justifying the diagnosis include sleep disturbances because he is under Ambien which at some point he used to harm self. The patient is also sad and hopeless hence the intentions to harm self (Mullen, 2018. The current medications the patient is taking is Zoloft 50mg po daily and the medication has been helping the patient. There is no change in medication that is to be introduced. The patient will continue with Zoloft 50mg po daily.
References
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Benazzi, F. (2022). Various forms of depression. Dialogues in clinical neuroscience.
Mullen, S. (2018). Major depressive disorder in children and adolescents. Mental Health Clinician, 8(6), 275-283.
Patient Narrative Note
Date Patient Seen; 7/18/22
Chief Complaint; The patient complained of depression which begun when he was 9 years.
History of Present Illness; According to the patient’s step dad, the patient was sexually abused when he was at the age of 9 years. The patient was also bullied at school and at some point, used his medication, Ambien with the intention to harm self. Currently, the patient is managed with Zoloft 10mg po daily and it is helping a little bit.
Mental Status Exam-
- According to mental examination, the patient has depression. Depression is a major symptom of Moderate major depressive disorder, recurrent episode (Benazzi, 2022).
- At some point wanted to harm self. Self-harm is also associated with Moderate major depressive disorder (Mullen, S. (2018)Assessment For Patient Complaining Of Depression Assignment.
Social history
Ø The patient lives with his mother and step dad.
- The patient doesn’t drink or smoke.
Diagnosis; F33.1 – Moderate major depressive disorder, recurrent episode
Signs & Symptoms that support the diagnoses
- The patient has sleep disturbances, takes Ambien
- The patient is sad, wanted to harm self
Medication with dose and frequency along with indication for treatment.
The current treatment regime for the patient includes Zoloft 10mg po daily which is used to manage the symptoms this was initiated one year after the onset of the symptoms.
Client progress to date
the step father reports that the patient has been doing well with Zoloft 10mg po daily because it has helped manage the symptoms.
Patient’s stated goals; N/A
Teaching goals and self-help strategies along with the content of instruction.
The teaching goals are to help the patient overcome depression and self-harm intentions witnessed when he took Ambien to intentionally harm self Assessment For Patient Complaining Of Depression Assignment
Treatment plan
The patient will continue with prior dose of Zoloft 50mg po daily.
References
Benazzi, F. (2022). Various forms of depression. Dialogues in clinical neuroscience.
Mullen, S. (2018). Major depressive disorder in children and adolescents. Mental Health Clinician, 8(6), 275-283.
Weekly Patient Narrative Note: PLEASE MAKE SURE ALL OF THESE ARE COVERED IN THE NARRATIVE
1. Date Patient Seen
2. Chief Complaint
3. History of Present Illness
4. Mental Status Exam- Include all aspects of the MSE along with justification for findings. Do not use a template where you just check off the different components of MSE.
5. Diagnoses (established in this treatment course or new for today’s visit) with ICD-10 code for each
6. Signs & Symptoms that support the diagnoses (This is medical Decision-Making)Assessment For Patient Complaining Of Depression Assignment
7. Medication with dose and frequency along with indication for treatment. The diagnoses and medication should be reflective.
8. Client progress to date if previously treated & on a current treatment plan (write n/a if this is first-ever treatment)
9. Patient’s stated goals.
10. Teaching goals and self-help strategies along with the content of instruction.
11. What changes to the treatment plan (if any) are needed at this time?
USE THIS PATIENT INFO TO MAKE YOUR NARRATIVE AND ADD REFERENCES PLEASE. THANKS. Any info I don’t have here, just make it up. Thanks
7/18/22
Info – patient complained of having depression starting at the ago of 9 never treated until about 1 year ago when he started taking zoloft. Patient came with step dad who added that patient was sexually abuse at age 9. Also reported that patient had taken his ambien with the intention to harm self. Step father said he was bullied in school. Symptoms currently managed with Zoloft 10mg po daily and helping a little bit
Past Diagnosis and Age of Onset
-Depression
-Bullied in school and sexually abused
ORDER TODAY
Social Hx
-Lives mother and stepdad
-Don’t smoke or drink
Dx
F33.1 – Moderate major depressive disorder, recurrent episode
Treatment Plan
Continue with prior dose of zoloft 50mg po daily. Given 15 days supply
Will see patient in 2 weeks for follow Assessment For Patient Complaining Of Depression Assignment