A case and treatment plan for a fictional or real client encountered in clinical practice.

Sample Solution

  Client Name: John Smith Age: 35 Gender: Male Marital Status: Single Occupation: Software Engineer Chief Complaint: John presents with a chief complaint of depression. He reports feeling sad, hopeless, and unmotivated. He has lost interest in activities he once enjoyed, such as spending time with friends and family, playing video games, and going to the gym. He has also experienced changes in his appetite and sleep patterns. He has been sleeping more than usual and has lost his appetite. He has also been having difficulty concentrating and making decisions.

Full Answer Section

    History of Present Illness: John's symptoms have been present for about 6 months. They began after he was laid off from his job. He had been working at the same company for 5 years and was very close to his colleagues. He was devastated when he was laid off and found it difficult to find a new job. He has been unemployed for 4 months and is starting to feel hopeless about his financial situation. He is also worried about how he will support himself and his family. Past Psychiatric History: John has no history of psychiatric illness. He has never been hospitalized for a mental health condition and has never taken medication for a mental health condition. Past Medical History: John has a history of hypertension and high cholesterol. He takes medication for both conditions. He is otherwise healthy. Social History: John is single and lives alone. He has no children. He has a close relationship with his parents and siblings. He is also close to his friends from work. He has been active in his community and volunteered at a local soup kitchen. He has stopped volunteering since he was laid off. Mental Status Examination: John is a well-groomed and well-dressed man in his early 30s. He is cooperative and polite. He is oriented to time, place, and person. His speech is fluent and coherent. His affect is sad and he appears to be downcast. He denies suicidal or homicidal ideation. His thought process is linear and goal-directed. He denies auditory or visual hallucinations. His insight and judgment are impaired. Diagnosis:

• Major Depressive Disorder, Single Episode, Moderate
• Adjustment Disorder with Depressed Mood

Differential Diagnosis:

• Bipolar Disorder
• Substance-Induced Mood Disorder
• Major Depressive Disorder, Persistent
• Psychotic Depression

Medical and Psychosocial Factors:

• Job loss
• Financial difficulties
• Social isolation
• Family history of depression

Treatment Plan:

• Medication: John will start taking an antidepressant medication.
• Therapy: John will start seeing a therapist for individual therapy.
• Support groups: John will join a support group for people with depression.
• Vocational counseling: John will receive vocational counseling to help him find a new job.

Prognosis: John's prognosis is good. He is a motivated and engaged client. He has a strong support system and is willing to participate in treatment. With medication, therapy, and support, he is expected to make a full recovery.