Dealing with Multiple Agencies and Integrating Contingency Planning

Case study to read below


Subjective Objective
The client is a 25-year-old, Latino male referred by his primary care provider for a psychiatric evaluation at an outpatient clinic.

Client’s Chief Complaints:

“I think I might be depressed.”


History of Present Illness

The client reports increasing depressive symptoms with onset three months ago. He is experiencing stress related to unemployment, financial strain, and needing to sell his home quickly because he cannot afford the mortgage. He reports depressed mood, low energy, low motivation, anhedonia, poor concentration, loneliness, low self-esteem, hopelessness, and decreased appetite with 12 lb. weight loss over the past month. He reports difficulty falling and staying asleep due to anxiety and restlessness, difficulty making decisions, and self-isolation. He endorses stress related to the abovementioned stressors, as manifested by restlessness, worry, and muscle tension. He reports that his current mental state is impeding his ability to apply for new employment and prepare his home for the impending sale.

Past psychiatric history: no previous history; this is the client’s first contact with a mental health provider.

Past Medical History: none

Family History

· Father is alive and well.

· Mother is alive, has had depression “all her life”

· One brother, age 18, alive and well

Social History

· Lives alone

· single

· does not have any friends

· alcohol use 1-2 times/week.

· no marijuana or illicit drug use

· attended one year of college.

Trauma history: Client reports was bullied in middle school due to his poor grasp of the English language at that time No reports of nightmares or flashbacks.

Review of Systems

· appetite diminished, weight loss 15 lbs

· sleeps 5-6 hours at night, difficulty falling asleep with frequent night waking.

· No headache

· No palpitations, tremors

Allergies: NKDA, allergic to grass, perennial trees, dust mites, and cockroaches.

Physical Examination:

Height: 65″, weight: 205 lb.

General: Well-nourished male appears stated age

Mental status exam:

Appearance: appropriate dress for age and situation, well nourished, eye contact poor, slumped posture

Alertness and Orientation: alert, fully oriented to person‚ place‚ time‚ and situation,

Behavior: cooperative

Speech: soft, flat

Mood: depressed

Affect: constricted, congruent with stated mood

Thought Process: logical‚ linear

Thought content: Self-defeating thoughts endorses thoughts suggestive of low self-worth. No thoughts of suicide‚ self-harm‚ or passive death wish

Perceptions: No evidence of psychosis, not responding to internal stimuli.

Memory: Recent and remote WNL

Judgement/Insight: Insight is fair, Judgement is fair

Attention and observed intellectual functioning: Attention intact for the purpose of assessment. Able to follow questioning.

Fund of knowledge: Good general fund of knowledge and vocabulary

Musculoskeletal: normal gait



Primary diagnosis: Major Depressive Disorder, single episode, moderate with anxious distress (F32.1)


a. Instructions-

b. Select one psychiatric drug to treat the diagnosis(es) or symptoms.

c. List medication class and mechanism of action for the chosen medication.

d. Write the prescription in prescription format.

e. Provide an evidence-based rationale for the selected medication using at least two scholarly reference.

f. List any side effects or adverse effects associated with the medication.

g. Include any required diagnostic testing. State the time frame for this testing (testing is before medication initiation or q 3 months, etc.). Includes normal results range for any listed laboratory tests.

h. Provide a minimum of three appropriate medication-related teaching points for the client and/or family.

Please use only a psych medication.

Please use one reference from- Stahl, S. M. (2021).  Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (5th ed.). Cambridge University Press.

05.23 CCK


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