A 28-year-old female presents to your office stating that she is troubled by headaches and fatigue

ANSWER SUMMARY

Summarize the Clinical Case: A 28-year-old female is experiencing headaches, fatigue, difficulty sleeping, a lack of interest in activities she used to enjoy, missing work, crying spells, weight loss, and difficulty concentrating. She has no significant past medical or psychiatric history and denies using alcohol or drugs. She is married with two children in elementary school.

List of Patient’s Problems and Prioritization:

1. Fatigue and difficulty sleeping
2. Headaches
3. Lack of interest in activities
4. Crying spells
5. Difficulty concentrating
6. Weight loss

Diagnosis to be Considered:

1. Major Depressive Disorder

Rationale for Diagnosis: The patient’s symptoms, including fatigue, difficulty sleeping, lack of interest in activities, crying spells, and weight loss, are consistent with the symptoms of Major Depressive Disorder (MDD). The difficulty concentrating and headaches may also be related to the depression.

Differential Diagnosis to be Considered:

1. Generalized Anxiety Disorder
2. Chronic Fatigue Syndrome
3. Thyroid Disorders
4. Vitamin Deficiency

Tests or Screening Tools to be Considered:

1. Depression screening questionnaire such as the Beck Depression Inventory (BDI)
2. Laboratory tests, such as a complete blood count (CBC), thyroid function tests, and vitamin levels
3. Sleep studies to rule out sleep disorders

Treatment:

1. Psychopharmacology: Antidepressant medication, such as selective serotonin reuptake inhibitors (SSRIs), may be prescribed to treat the depression.
2. Diagnostic Tests: Laboratory tests and sleep studies to rule out any underlying medical conditions.
3. Referrals: Referral to a therapist or counselor for psychotherapy and psychoeducation.
4. Psychotherapy: Cognitive-behavioral therapy (CBT) and/or interpersonal therapy (IPT) may be recommended to help the patient manage her depression and related symptoms.

Standard Guidelines:

1. American Psychiatric Association (APA) diagnostic criteria for Major Depressive Disorder as listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5)
2. National Institute for Health and Care Excellence (NICE) guidelines for the treatment of depression
3. The American Academy of Sleep Medicine (AASM) guidelines for the diagnosis and treatment of sleep disorders.

Antidepressant Agents

Instructions: Case Discussion on Depression:

A 28-year-old female presents to your office stating that she is troubled by headaches and fatigue. She says that she always feels tired and can’t sleep well, often waking up early if she gets to sleep at all. She describes her headaches as dull, aching, and generalized. These symptoms began about three weeks ago and have been getting worse. She reports a lack of interest in her usual activities, even the ones that she used to enjoy. She also reports that she is missing work due to fatigue and inability to concentrate. Although both her children are in school, she is concerned that she is “losing them”. She is worried that she might have “something bad” because she has difficulty concentrating and is having frequent crying spells. She reports a loss of appetite, with a weight loss of 10 pounds in the last month.

The patient has no significant past medical or psychiatric history and takes no regular medications. However, she takes ibuprofen for headaches. She denies using alcohol or drugs. The patient is married, with two elementary school-age children.

• Summarize the clinical case.
• Create a list of the patient’s problems and prioritize them.
• Which diagnosis should be considered
• What is your rationale for the diagnosis
• What differential diagnosis should be considered
• What test or screening tools should be considered to help identify the correct diagnosis
• What treatment would you prescribe and what is the rationale (consider psychopharmacology, diagnostics tests, referrals, psychotherapy, psychoeducation)
• What standard guidelines would you use to assess or treat this patient

Responses need to address all components of the question, demonstrate critical thinking and analysis and include peer-reviewed journal evidence to support the student’s position.

Submission Instructions

• Your initial post should be at least 500 words,formatted and cited in current APA style with support from at least 2 evidence-based sources.