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A clinical case study of a 20-year-old female diagnosed with major depressive disorder with a seasonal pattern (sad). It includes subjective information gathered from the patient, her history, and a mental status examination. The assessment section details the diagnostic criteria for sad according to dsm-5, along with differential diagnoses such as adjustment disorder and bipolar ii disorder. The plan outlines a comprehensive treatment approach, including light therapy, cognitive behavioral therapy (cbt), and medication (sertraline), with considerations for follow-up appointments and patient education. References to relevant psychiatric literature and resources are also provided, enhancing its educational value for students and practitioners in the mental health field. This case study offers a practical understanding of diagnosing and managing sad, making it a valuable resource for those studying or working in psychiatry and related disciplines.
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Criteria Clinical Notes Subjective CC : “Mom says I get moody this time of year, every year.” HPI : M.B. is a 20-year-old Caucasian female who presented to the clinic for evaluation since her mother has been complaining that she always gets moody during winter time. She reported that recently, she has been feeling down, fatigued during daytime, oversleeping during her classes, and gaining 10 pounds weight. She reported that she has been having difficulties in school where she feels that even though she understands the material, the classes are not interesting anymore. She reported that she has a difficult time completing her school projects, and even running late on two assignments. M.B. stated that has a difficult time concentrating, being unable to remember what she has read 5 seconds earlier. Patient stated that she made a lot of friends when she first started college, in August, and greatly enjoyed their company but lately she finds them a bit annoying and dull, and their time spent together decreased drastically. M.B. reported that she is a summer girl, loves the sunny ,crips days, enjoys the beach and convertibles, but does not like this season (winter) because “it’s dark. And gray. And miserable”. She reported that during the winter the city seems changed, getting worse and worse, and everything is now grey and miserable. Past Psychiatric History :
back home. She moved to NY in August to attend a business program, lives in a dorm with one roommate, and does not have any children. She is a full-time student, no violent or traumatic past. Hobbies: hangs out with friends, traveling and hiking. Past Medical history : Reports no chronic illnesses. Reports regular menses, denies taking any type of contraceptives and denies being sexually active. Past Surgical history : Reports an appendectomy at age 15. Medications : none Allergies : No food/medication allergies. No seasonal allergies. Spiritual history : Catholic but not practicing. Immunizations: All vaccinations are up to date Primary Care Physician : Patient does not see a physician regularly.
General : M.B denies fever, generalized weakness, or chills. She has a recent history of 10 lbs weight gain, and fatigue. HEENT: Head, neck, lymph: Denies any pain or discomfort. Nose, sinuses: Denies pain. No epistaxis or rhinorrhea. Throat, mouth, pharynx: Denies pain or difficulty with swallowing. Neuro: Denies dizziness, numbness or tingling. Reports sleeping excessively and difficulty concentrating. Pulm: Denies congestion or dyspnea. Denies cough. Cardio / vascular: Denies chest pain. Denies cough or dyspnea on exertion. Denies any palpitations or heart murmurs. GI / Abdomen: Denies any nausea, vomiting, diarrhea or constipation. Denies any epigastric or abdominal pain. Reports an increased appetite G/U: M.B. denies burning with urination, hematuria, frequency, dysuria, viaginal discharge or incontinence. Objective Vital Signs BP: 112/76 HR: 79 RR: 18 SPO2: 97% T: 98. Pain: 0/ Height: 5’5 Weight: 165 BMI: 27.5 (risk of being overweight) Diagnostic results: HAM-D: 18 moderate depression CBC: normal TSH: normal Blood alcohol content (BAC): normal Vitamin B12: normal Vitamin D: low Mental Status examination M.B. is a young Caucasian female, who seems to be the stated age, This is where the “facts” are located. Include relevant labs, test results, vitals, and Review of Systems (ROS) – if ROS is negative, “ROS noncontributory,” or “ROS negative with the exception of…” Include MSE, risk assessment here, and psychiatric screening
& titration considerations, lab work ordered, referrals to psychiatric and medical providers, therapy recommendations, holistic options and complimentary therapies, and rationale for your decisions. Include when you will want to see the patient next. This comprehensive plan should relate directly to your Assessment. D, light therapy, and psychotherapy (CBT) is recommended. The patient will begin bright-light therapy (provide referral), cognitive behavioral therapy (referral), and give a prescription for 50 mg of oral sertraline daily (may increase to 100 mg based on clinical response if needed). Patient will have a first follow-up appointment in 2 weeks, and then regular follow-up appointments (every 4-6 weeks) to monitor symptoms, medication efficacy, and any side effects are important to adjust treatment as necessary. M.B. will be advised on the benefits of joining support groups (provide recommendations if needed), sleep hygiene, exercising regularly, and maintaining a balanced and healthy diet.