Review the Depression Case Study patient scenario and analyze the data to determine the patient’s health status.
For this assignment:
Diagnosis(es): MDD, most recent episode mild without psychotic features.
Treatments: Medications only.
Medications: Lexapro 10 mg PO QD.
Previous Medication Trials: Prozac for 18 months then changed to Lexapro three months ago.
Therapy: Referred to CBT but never attended.
Previous Therapy Trials: None.
Outcomes: Had response to medication two years ago; changed meds, response initially on Lexapro, now symptoms worsening.
Mrs. Lane is the youngest of six children born to biological parents who raised her in South Korea . She completed high school in South Korea. She came to the U.S. as a young adult at age 18 and she received a licensed vocational nursing (LVN) degree later. Received a Green Card and then became a U.S. citizen years later. All her family of origin live in South Korea except her twin sister, and she visits South Korea every two to three years. Lives with her husband of 20 years. No history of alcohol or drug use. Currently works as a LVN at a retirement home. She has two grown children, both daughters, and one grandson who is three years old. One daughter lives in California and the other daughter lives in town with her husband and son. They visit frequently and live only a few houses down from Mrs. Lane. Her twin sister also lives next door, and they see each other daily.
Spirituality: None
Last immunizations: Flu vaccine, one year ago; recent Covid vaccine, plus boosters X 2. Visited family in South Korea two years ago.
Regularly wears seatbelt when riding as passenger.
No weapons in the home.
Reports usual health as “good.” Denies fever, chills. Endorses some weight loss changes of five pounds in last month.
Denies chest pain, palpitations.
Admits depressed mood, and she is “frustrated” that her anxiety is worsening. Admits to some apathy and decreased motivation. Denies suicidal or homicidal ideations.
Admits insomnia, difficulty falling asleep, some middle-night awakening, and disruption of 24-hour sleep cycle. Does report “wanting to sleep much more” and “no energy in the morning.” Additionally reports waking up in sweats.
Admits loss of interest or pleasure in activities and social isolation. Specifically her favorite thing, Saturday cooking, is no longer a priority.
Denies feelings of helplessness, hostility, low self-esteem, guilt, or shame. Endorses some feelings of hopelessness in her condition not improving.
Denies increased energy but does occasionally feel fatigued.
Has noticed she has some difficulty concentrating, has stopped watching TV, and is very forgetful at times. “I leave my keys everywhere and misplace my phone all day. That’s not normal for me. Sometimes, I just cannot retrieve words when I am trying to talk.”
Endorses increase in appetite. “I had surgery to lose weight and I’m gaining it back. I can’t get enough to eat.”
Denies delusions, hallucinations, feelings of persecution, hearing sounds that seem to be voices, or preoccupation with religion.
Denies self-inflicted injuries; has no frequent thoughts of death, lack of desire to continue living, or suicidal tendency.
Denies homicidal thoughts.
Denies family problems, poor school/work performance, recent separation, job loss, and legal problems; not under stress other than worrying about increased anxiety and feeling overall worse.
| Height | 63 inches |
|---|---|
| Weight | 150 lbs. |
| Waist circumference | 40 |
| T | 98.9 |
| P | 82 |
| R | 18 |
| BP | 144/86 |
| BMI | calculate at each visit |
Mrs. Lane is a 42-year-old South Korean American female who articulates very clearly, is not unsteady, ambulates without difficulty, and is in no acute distress. General appearance same as stated age, normal level of personal hygiene; no inappropriate clothing, no bizarre personal appearance, no body odor.
Remainder of physical exam deferred during psychiatric mental health assessment.
A&O x 4, disheveled appearance. No spontaneous speech, but answers questions when asked.
No noted hypervigilance, heightened startle reflex, abnormal mannerisms, or uncommunicative/disinterested/hostile/inattentive attitude.
No tremor or tics; normal gait and stance; no involuntary movements.
No refusal to speak or loosening of association/word salad; not slowed, rapid, or difficult; normal rhythm of speech, speech tone, and speech volume.
Appears depressed; does not appear anxious, dysphoric, euphoric, elevated, expansive, irritable, or angry.
Full ranging, not blunted, constricted, flat, incongruent with mood, inappropriate, labile, sad, or tearful.
No language abnormalities; speech fluent; no dysphonia; no stuttering; language fluent and intact for naming; normal sentence structure.
Patient oriented x4; no disorientation, short-term memory impairment, reduced abstraction ability, or diminished cognitive functioning. Some delay in retrieving thoughts.
No deficiency on evaluation of connectedness; organized.
No thought content impairment; no suicidal ideation, homicidal ideations, paranoid ideations, poverty of thought, thought insertions, obsessions, irrational fears, delusions, or hallucinations.
No impaired insight, impaired judgment, or poor problem solving.
No recent labs on file.