Treatment plan for a fictional or real client encountered in clinical practice.
Develop and present a case and treatment plan for a fictional or real client encountered in clinical practice.
Sample Solution
Client: The client is a 55-year-old man named John Smith. He is a retired construction worker who lives with his wife and two adult children. He is currently unemployed and has been experiencing difficulty finding a new job. Chief Complaint: John's chief complaint is fatigue. He says that he has been feeling tired all the time, even after he gets a good night's sleep. He also reports having difficulty concentrating and feeling forgetful. History of Present Illness: John's fatigue has been getting worse over the past few months. He says that he used to be able to go for long walks and play with his grandchildren, but now he gets tired after just a few minutes of activity. He has also been having trouble concentrating at work and has made some mistakes that he never used to make.Full Answer Section
John's wife says that he has also been more forgetful lately. He has forgotten things like appointments and names of people he knows. She is also concerned about his mood. He has been more irritable and withdrawn lately.
Past Medical History:
John has a history of hypertension, high cholesterol, and diabetes. He takes lisinopril, atorvastatin, and metformin for these conditions. He also has a history of depression.
Social History:
John is married and has two adult children. He is retired from construction work and has been unemployed for the past six months. He is currently looking for a new job. He drinks alcohol socially and does not smoke.
Review of Systems:
John's review of systems is positive for fatigue, difficulty concentrating, forgetfulness, irritability, and withdrawal. He denies any other symptoms.
Physical Examination:
John's physical examination is unremarkable. His vital signs are within normal limits. His height is 6 feet and his weight is 200 pounds. His BMI is 27. He has no jugular venous distension, carotid bruits, or peripheral edema. His lungs are clear to auscultation. His heart rate and rhythm are regular. His abdomen is soft, non-tender, and non-distended. His neurological examination is normal.
Laboratory Tests:
John's laboratory tests are unremarkable. His complete blood count, chemistry panel, and thyroid function tests are all within normal limits.
Imaging Studies:
John's chest X-ray is normal. His electrocardiogram is normal.
Diagnosis:
John's diagnosis is major depressive disorder. His fatigue, difficulty concentrating, forgetfulness, irritability, and withdrawal are all symptoms of depression. His history of hypertension, high cholesterol, and diabetes is also consistent with depression.
Treatment Plan:
John's treatment plan includes:
- Psychotherapy: John will see a therapist once a week to discuss his depression and develop coping strategies.
- Medication: John will start taking an antidepressant medication, such as sertraline or citalopram.
- Lifestyle changes: John will make lifestyle changes to improve his overall health, such as eating a healthy diet, exercising regularly, and getting enough sleep.