Patient: Ms. Jane Doe
Civil Status: Married
Type of Admission: Voluntary
Ms. Doe is a 30 year old white female. She is married and lives at home with her husband, her four children (ages 11, 9, 6, and 4 yrs). Her youngest brother lives in the home with them, also. She is a graduate from Jones High School and is currently unemployed. Ms. Doe does not drink alcohol; however, she does have a positive history of illicit drug abuse (marijuana) but quit in 2001. She engages in smoking a synthetic form of cannabis in addition to a cigarette habit of 1-2 packs per day since 2009. She states that she is trying to quit the smoking habit, but that it is very difficult.
History of Present Illness: Ms Doe presented to the facility with her husband with increased anxiety and depression. In addition, she has been experiencing hallucinations and hearing voices. Her husband brought her to the facility because they both feared for the welfare of their children. She has not been able to sleep for about 1 week and has been having severe panic attacks for 2 weeks prior to admission. She states that her stress has increased due to having to care for her 4 year- old with developmental delays and that her family is experiencing added financial stress.
Patient Medical/Surgical History: Mood disorder/Depression, Substance Abuse, Anxiety, Cluster B Personality Trait, Asthma, Smoking Addiction, Peripheral Vascular Disease, UTI.
I. Diagnosis: Depression
▪ Depressive disorders affect approximately 18.8 million American adults or about 9.5% of the U.S. population age 18 and older in a given year. Depression is a serious medical illness that involves the brain. It's more than just a feeling of being "down in the dumps" or "blue" for a few days. If you are one of the more than 20 million people in the United States who have depression, the feelings do not go away. They persist and interfere with your everyday life. Depressive disorders are common: about 20% of women and about 10% of men may suffer from major depression at some point during their lives. Depressed patients have more medicall illnesses and higher risk of self-injury and suicide than patients without mood disorders. ▪ A condition of mental disturbance, typically with lack of energy and difficulty in maintaining concentration or interest in life. One or several mood disorders marked by loss of interst or pleasure in living. Disorders linked to depression include major depressive disorder, schizoaffective disorders, bipolar disorders, seasonal affective disorders, and postpartum depression disorder. ▪ The patient is assessed for feelings of worthlessness or self-reproach, inappropriate guilt, concern with death, and attempts at self-injury. Level of activity and socialization are evaluated. Adequate nutrition and fluids are provided. Dietary interventions and increased physical activity are recommended to manage drug-induced constipation; assistance with grooming and other activities of daily living may be required. ▪ A structured routine, including noncompetitive activities, is provided to build the patient's self-confidence and to encourage interaction. Health care professionals should express warmth and interest in the patient and be optimistic while guarding against excessive cheerfulness. Support is gradually reduced as the patient demonstrates an increasing ability to resume self-care. ▪ Drug therapies are administered and evaluated: these may include tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), selective norepinephrine and serotonin reuptake inhibitors, dopamine-norepinephrine reuptake inhibitors, and norepinephrine-serotonin modulators. Monamine oxidase (MAO) inhibitors also may be...
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