Tag: Summarizing a clinical case

Reggie is a 42-year-old African American male recently referred for outpatient psychotherapy by his PCP. While he is in relatively good health, he admitted to his doctor that he has been drinking alcohol excessively again over the last three months. Reggie had a problem with alcohol when he was in his twenties, but with the help of AA and his first male partner, he was able to cease drinking for the last 19 years. Reggie admits that it has not always been easy for him to abstain, but he is committed to trying again. He has attended AA meetings but has not been able to maintain complete sobriety. On average, he has one or two drinks nearly every evening. His partner, Bob, has a zero-tolerance policy for Reggie’s drinking and has moved in with a friend rather than deal with Reggie’s promises to stop. Reggie is worried that Bob may not come back. Reggie does not want to end up like his father, who drank himself to death at the age of 56. His father and mother divorced when Reggie was only 15. Reggie’s only sister had a serious addiction to benzodiazepines and spent 28 days in a rehab center. She is clean now but also abuses alcohol on occasion.

Questions:Remember to answer these questions from your textbooks and clinical guidelines to create your evidence-based treatment plan. At all times, explain your answers.

Summarize the clinical case.
What is the DSM5 diagnosis? Identify the rationale for your diagnosis using the DSM5 diagnostic criteria.
According to the clinical guidelines, which one pharmacological treatment is most appropriate to prescribe? Include the medication name, dose, frequency and rationale for this treatment.
According to the clinical guidelines, which one non-pharmacological treatment would you prescribe? (exclude psychotherapy modalities) Include the risk and benefits of the chosen rationale for this treatment.
Include an assessment of medication’s appropriateness, cost, effectiveness, safety, and potential for patient adherence.

Case Study

Ms. Z is a 28-year-old assistant store manager who arrives at your outpatient clinic complaining of sadness after her boyfriend of 6 months ended their relationship 1 month ago. She describes a history of failed romantic relationships, and says, “I don’t do well with breakups.” Ms. Z reports that, although she has no prior psychiatric treatment, she was urged by her employer to seek therapy. Ms. Z has arrived late to work on several occasions because of oversleeping. She also has difficulty in getting out of bed stating, “It’s difficult to walk; it’s like my legs weigh a ton.” She feels fatigued during the day despite spending over 12 hours in bed and is concerned that she might be suffering from a serious medical condition. She denies any significant changes in appetite or weight since these symptoms began.

Ms. Z reports that, although she has not missed workdays, she has difficulty concentrating and has become tearful in front of clients while worrying about not finding a significant other. She feels tremendous guilt over “not being good enough to get married,” and says that her close friends are concerned because she has been spending her weekends in bed and not answering their calls. Although during your evaluation Ms. Z appeared tearful, she brightened up when talking about her newborn nephew and her plans of visiting a college friend next summer. Ms. Z denied suicidal ideation.

Questions:

Remember to answer these questions from your textbooks and clinical guidelines to create your evidence-based treatment plan. At all times, explain your answers.

Summarize the clinical case including the significant subjective (patient stated data) and objective data (provider assesed data).
Generate a primary and two differential diagnoses. Use the DSM5 to support the assessment. Include the DSM5 and ICD 10 codes.
Discuss a pharmacological treatment would you prescribe? Use the clinical guidelines to support the rationale for this treatment.
Discuss non-pharmacological treatment would you prescribe? Use the clinical guidelines to support the rationale for this treatment.
Describe a health promotion intervention that would be appropriate for this patient.

A 25-year-old male presents to your clinic because he is having difficulty his new job. He works at a consulting firm. He states it is hard for him to give presentations due to concerns that he will embarrass himself and his peers will think less of him. To avoid being put on the spot, he has passed up multiple lead roles and potential promotion as a result. He says this is frustrating because he doesn’t have an issue interacting with peers in small groups or friends and in no work settings.

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.