Case Study WEEK 7: M. Robinson

Case Study WEEK 7: M. Robinson

Subjective

The client’s primary complaint is that she has anxiety and depression. She claims that she has been experiencing these symptoms since 2018 and that they have worsened after her son was killed in August of the same year. She recommends experiencing racing thoughts, restless sleep, impatience, and lack of focus or attention. She claims to have no hallucinations or suicidal or violent thoughts. In addition to anxiety and sadness in 2018, the patient also had a turbulent domestic relationship in 2019 that involved verbal, emotional, and physical violence. The patient has a history of using Xanax, Wellbutrin, and Lexapro and experiencing auditory hallucinations and frenzied thoughts following her son’s death in August 2021. The patient disavows having any ongoing health issues, using illegal substances, smoking, or having any prescription allergies. Some of the client’s troubling symptoms are anxiety, sadness, auditory hallucinations, racing thoughts, sleeplessness, irritability, poor focus/concentration, and frequent sobbing. Through their experiences of racing thoughts, sleeplessness, irritability, poor focus/concentration, and isolation, the client’s symptoms are affecting how they can perform. The client finds it challenging to manage these symptoms in their daily lives.

Objective

Diagnostic results presenting the history of the prevailing condition

The client said during the interview that she had experienced anxiety and despair since 2018. She stated that she was being treated with Lexapro, Wellbutrin, and Xanax at the time, but she stopped taking medicine after three months because she thought it was ineffective. The client additionally disclosed that in 2019, they were a part of a turbulent domestic situation that included verbal, emotional, and physical assault. The client’s kid was murdered in August 2021, and she started having auditory hallucinations. Since then, she has endorsed racing thoughts, sleeplessness, feeling exhausted upon awakening, anger, irregular eating without noticeably changing weight, isolation, frequent sobbing, and lack of attention and concentration (Ströhle et al., 2018). The individual denied having any ongoing health issues, using illegal substances, smoking, or having any sensitivities to medications.

Assessment

The client receives orientation to time, location, and people. She thinks logically and with clarity. She can give a succinct and precise summary of her past. She has sound judgment and understanding. She can explain her present symptoms in plain and simple terms. She experiences all the human emotions. She cooperates during the interview and is always agreeable. There are no indications of psychosis in her.

Differential diagnoses and rationale

1. Major depressive disorder, recurrent, moderate - due to the client’s history of depression and the current symptoms she is experiencing.

2. Generalized anxiety disorder - due to the client’s history of anxiety and the current symptoms she is experiencing.

3. Post-traumatic stress disorder, chronic - due to the client’s history of trauma and the current symptoms she is experiencing.

What has to be changed?

Different approaches should be employed in various circumstances. Understanding the client’s background in detail is the first step. Unfortunately, the perfect reason for the client’s lack of adherence and stoppage of taking the prescribed medication is not provided. Additionally, the domestic situation in 2019 is not elaborated on effectively. It is possible that the domestic situation was an aggravating factor in their mind which can also be why the client stopped attending to the prescribed medication. Having detailed information about the client’s history will make it easier to find appropriate answers and confirm the presented hypothesis, effectively providing additional treatment to help improve the client’s condition.

The second concern that needs to be done differently is assessing the client’s mental system. Based on the information provided about the client’s mental state, the client currently experiences hallucinations and delusions. Therefore, the client’s mental state needs to be properly assessed to ensure that there are no delusions or hallucinations. Additionally, assessing the client’s alcohol intake is critical. The rationale behind the assessment of alcohol intake assessment is to manage the intake and reduce the depressive and anxiety symptoms that are all associated with uncontrolled and excessive alcohol consumption. Lastly, it is also vital to ensure that the client does not engage in the intake of any illicit drugs. Prevention of illicit indulgence reduces the risks of anxiety, depression, or even domestic violence provided to the client. HealthyPeople 2030’s definition of social determinants of health (study needed) applies to this situation in the psychotherapy and psychological health fields.

Economic stability is one of the social determinants of health applicable to the presented case. Being economically stable is an insinuation of having all the needed resources for a healthy life (Islam, 2019). An economically stale individual can access health facilities without struggle, attend the best education, and access all the leisure without struggle. According to the data in the research study, the client’s anxiety and sadness may be adequately explained by economic instability. According to the information provided about the client, the client has a history of anxiety and depression that can be traced back to 2018 when she was being treated using Lexapro, Wellbutrin, and Xanax. The client, however, stopped because she felt it was not working out and could not receive further treatment due to economic strain (Islam, 2019). She was a part of a turbulent domestic situation in 2019 that included verbal, emotional, and physical assault. Since the outset, she has experienced various symptoms, including racing thinking, sleep problems, a sense of exhaustion when she wakes up, anger, intermittent eating without appreciably affecting her weight, social isolation, distress, and trouble concentrating. Initially, she claims she was experiencing auditory hallucinations. Therefore, the client’s economic strain is a social focus affecting her psychiatry and mental realm.

Future Healthcare Consideration and Education Consideration for the Client

For this patient, the health promotion activity may center on assisting her in creating a support network. This can entail giving her information about support groups and contacting neighborhood resources and social agencies (Lu et al., 2020). In addition, the healthcare professional could advise the patient to engage in relaxation and self-care practices like yoga or meditation. From the case study, the patient seems to be living a solitary life, especially after the death of her child. Therefore, creating a support network will assist in empathetic strategies to improve her depression and anxiety.

Educating the patient on the causes and management strategies for the patient’s healthcare consideration. Patient education entails informing the patients of their medical issues and the predisposing factors to their prevailing condition (Yen & Leasure, 2019). Patient education also instills knowledge into the patients over the dos and the don’ts as far as their health is concerned. It’s crucial to tell the patient about her mental health concerns and available treatments as part of patient education. Additionally, it’s critical to inform the patient of the warning signs and symptoms of mental health issues and how to get assistance if she encounters a crisis (Yen & Leasure, 2019). For the patient provided within the case study, the patient needs to be told about the non-pharmacological interventions for managing anxiety disorder and depression. The patient should also get education regarding the significance of taking prescribed drugs and the repercussions of doing otherwise.

References

Islam, M. M. (2019). Social Determinants of Health and Related Inequalities: Confusion and Implications. Frontiers in Public Health, 7(11). https://doi.org/10.3389/fpubh.2019.00011

Lu, Y., Luo, S., & Liu, X. (2020). How do patients with depression develop social support networks through online health communities? A social network analysis from an online depression community (Preprint). JMIR Medical Informatics. https://doi.org/10.2196/24618

Ströhle, A., Gensichen, J., & Domschke, K. (2018). The Diagnosis and Treatment of Anxiety Disorders. Deutsches Aerzteblatt Online, 115(37). https://doi.org/10.3238/arztebl.2018.0611

Yen, P. H., & Leasure, A. R. (2019). Use and effectiveness of the teach-back method in patient education and health outcomes. Federal Practitioner, 36(6), 284–289. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6590951/