Name: ______________________________ Date: _________________ DOB: ________________
Age: ________________________________ Start Time: ____________ End Time: ___________
Identifying Information:
David is a self-referred 49-year-old, in a ‘typical’ relationship with wife and two adult children at first resisting treatment with the notion that his mood swings will, in the long run, be better. The treatment being sort, therefore, entails dealing with the feelings of melancholy and depression.
Presenting Problem:
The Client reports that he is not contented with his job, thus not enjoying it, reduced levels of appetite, various instances of feeling ‘down’ and unhappy, the lack of the inclination to do things which he used to formerly, preference for solitude, unsuccessful attempt to get out of the current mood swings, suicidal thoughts “life is hardly worth living.”
Life Stressors:
The Client’s life stressor entails his ‘typical’ relationship with his wife. Despite the couple not being in love with each other anymore, they are still clinging to each other based on the standard routine and accommodation.
Substance Use: Yes No
The client reports using alcohol at night due to a lack of sleep. He claimed that he used to partake in alcohol more regularly during his young years. Now he only drinks an estimated 2-3 beers per night.
Addictions (i.e., gambling, pornography, video gaming)
Addiction was assessed, and no current or past addiction ideations from the Client were reported.
Medical/Mental Health Hx/Hospitalizations:
This was assessed, and the Client reported neither a previous history of mental health nor hospitalizations based on mental concerns in his lifetime.
Abuse/Trauma:
This was assessed, and no current or past abuse/trauma was reported.
Social Relationships:
The Client’s social relationship mainly entailed family gatherings, where he would have recurring interactions with his children.
Family Information:
The Client reports his sister used to have the same depression problem, which she battled for over ten years. His sister’s emotional and physical exhaustion had escalated in the past, with her having a negative viewpoint claiming that when things seem bright, something immensely wrong happens. He now reports that his sister is seeing a psychiatrist and counselor.
Spiritual:
This was assessed, and it was evident that the Client has no history of spiritual involvement.
Suicidal:
This was assessed, and no current or past suicidal ideas were reported. However, the Client reports that “life is hardly worth living at times.”
Homicidal:
This was assessed, and no current or past homicidal ideations or involvement were reported.
Assessment:
The Client David, 49 years old, who is in a typical relationship with his wife, is not contented with being a metallurgical engineer. This lack of contentment resulted in mood swings, reduced appetite, lack of inclination to do things that he used to do formerly, and a preference for solitude. The Client also reported suicidal thoughts, all of which point to symptoms of severe depression and melancholy.
Initial Diagnosis (DSM):
Based on the DSM-5 as the basis of the diagnosis, Client David, 49 years of age, may have a major depressive disorder. This diagnosis is attributed to the symptoms depicted by the Client, including numerous mood swings, reduced levels of appetite, lack of morale and inclination to do things, and the preference for solitude. Suicidal thoughts were also included in the initial diagnosis. Together, these factors all point to major depressive disorder based on the DMV-V, which points to factors like fatigue, death thoughts, and depressed moods as signs of such a condition. Impairment, temperamental and suicidal risks are the functional consequences that may come with major depressive disorder (DSM-5, 2013).
Initial Treatment Goals:
The initial treatment goals include getting the Client to take part in a self-care plan, referring to a primary care physician to tackle the symptoms of the Client to rule out any other symptoms that may have been assumed, coming up with a treatment plan, developing a safety plan to act as back up for the Client’s suicidal risk and finally ensuring that the Client is open to counseling.
Plan:
The severity of David’s symptoms will be evaluated to determine if it would be suitable to admit or refer the case to a more specialized psychiatrist. The plan of action entails a screen test for the Client, as Anderson (2015) proposed. The nurse offers a two question inquiry on the symptoms of depression, which influences additional inquiry and evaluation The Beck Depression Inventory (BDI) which is considered as the most suitable depression evaluation tool for examining the acuteness of the Client’s symptoms due to the reason that it is the commonly utilized evidence based evaluation tool for depression. The assessment would thereafter determine whether the Client is to be admitted or not.
Name: _____________________________________________ Date: __________________
References
American Psychological Association. (2011). Beck depression inventory (BDI). Https://Www.Apa.Org. https://www.apa.org/pi/about/publications/caregivers/practice-settings/assessment/tools/beck-depression
Anderson, D. (2015). Depression: to screen or not to screen? Age and Ageing, 44(5), 728–729. https://doi.org/10.1093/ageing/afv097
DSM-5 (2013). Diagnostic and statistical manual of mental disorders DSM-5 (5th ed., pp. 155-170). American Psychiatric Association.