Reference no: EM133878106
Psychological Disorders Case Study
SUBJECTIVE
Sally is a 33-year-old married Caucasian female who works for a local newspaper and presents to your office with complaints of problems sleeping, fatigue, and difficulty "getting going." She reports intermittent awakening and usually has trouble waking up in the morning. She states she lies in bed in the morning and can't get up. She reports difficulty concentrating during the day, often losing her thoughts, and has difficulty at work due to this. Recently, it has taken her longer to complete her work. She fears that if she doesn't start sleeping soon, she will lose her job because she is not performing at her usual level; in addition, she is tired and irritable and is not getting along as well as usual with colleagues or family members. She said she always feels tense and has difficulty getting her job fears out of her mind. These symptoms have been increasingly difficult in the past 2 months, but present to a lesser degree over the past 8 months since she changed jobs. It is typical for her to wake up more than once during the night now; however, she never struggled to get back to sleep previously.
Past medical history: She reports having similar sleep problems after her college graduation, when she wasn't sure what to do with her life. The sleep problems and anxiety resolved after she found a part-time job, and then she was hired by the company full-time. She denies a prior history of psychiatric disorder or treatment. She has a history of gastroesophageal reflux disease (GERD). She has no other prior history of medical problems. She had a 30-lb weight gain after her first pregnancy, which she has been unable to lose. She has never had surgery.
Family history: She has a family history of ischemic heart disease in her father and uncles, and breast cancer in a maternal aunt. She denies a family history of psychiatric disorders.
Social history: She denies smoking, but drinks 1-2 glasses of wine with dinner. She is married and has two children, ages 4 and 7. She has been more irritable with her family recently. They live in a large suburban town in a condominium complex. Her husband works at a local factory on the evening shift; she works days at a local newspaper. She has a few friends at work and a few friends from college who are not local. She sees friends less since having children. Her social life surrounds the activities of her children and husband. She has a degree in graphic arts, likes music, and likes reading.
Medications: Pantoprazole, 40 mg PO QD.
Allergies: None.
OBJECTIVE
General: Sally appears restless and has dark circles under her eyes.
Vital signs: BP 118/72; pulse: 94; RR: 20; temperature: 98.6; height: 5 ft 4 inches; weight: 169 lbs.; BMI: 29.
Psychological Disorders Case Study (USE apa references in text 7th edition)
CRITICAL THINKING
- Which diagnostic or imaging studies would you consider to assist with or confirm the diagnosis? Add rationale.
- What are the three most likely differential diagnoses and why? If this is a psychological diagnosis, choose from the DSM-5 diagnostic criteria.
- What is your treatment plan?
- What is the plan for follow-up care?
- Are any referrals needed at this time?
- Does the patient's psychosocial history impact how you might treat this patient?