ROSA LEE CASE STUDYIDENTIFYING INFORMATION: Jane M. is self-referred 28 year old, divorced Caucasian female with no children or history of pregnancy seeking treatment to deal with feelings of hopelessness and depression.
PRESENT PSYCHIATRIC ILLNESS/SYMPTOMS: Client reports episodes of crying daily for the past month, difficulty focusing at work, inability to do chores at home (laundry, cleaning), isolating from friends and family, weight loss of 15 lbs in the past three weeks without dieting, insomnia (sleeping an average of 4-5 hours in 24), some thoughts of death, “it would be easier if I were dead”
PAST HX OF TREATMENT: Client reports one prior episode of major depressive symptoms three years ago for which she sought psychiatric care from Dr. Smith and underwent pharmacotherapy for 6 months with success, denying side-effects with the use of Paxil. She also reports attending a self-help group at her church and finding the support helpful. During her sophomore year in high school, she saw a school counselor for a few times following the separation and divorce of her parents to help with coping skills and grief/loss issues.
MENTAL HEALTH MEDICATIONS: No current use, previous course of Paxil with good efficacy, two trials of other medications during the same time that were unsuccessful. Client agrees to a release of information to seek additional information from Dr. Smith.
MEDICAL CONCERNS: Client reports recent gastro-intestinal upset, frequent diarrhea, nausea and headaches for which she has not sought medical attention. She denies any significant medical history, surgeries, pregnancies or disabilities.
CURRENT MEDICATIONS: Client reports taking over-the-counter anti-diarrheal medications and NSAID pain relievers.
DEPENDENCY/ADDICTION HISTORY: Client reports first use of alcohol at age 17, drinking two beers at a party and becoming intoxicated. She denied enjoying the experience but reports continued experimentation with alcohol one or...