READ BELOW-
Subjective Data
Chief Complaint:
The patient, a 31-year-old female, reports feeling persistently sad and anxious for the past
five months. She states, “I feel like I’m in a fog and can’t get out.”
History of Present Illness:
The patient describes a gradual onset of symptoms following the birth of her second child.
She has experienced significant mood swings, irritability, and overwhelming fatigue. She
reports sleeping poorly, often waking up several times a night and having diQiculty falling
back asleep. Her appetite has decreased, leading to a weight loss of about 10 pounds over
the last month. She expresses feelings of inadequacy as a mother and worries constantly
about her children’s well-being. Although she denies suicidal ideation, she admits to
feeling hopeless about her situation.
Demographic Data:
Age: 31 years
Gender: Female
Ethnicity: Asian American
Occupation: Elementary School Teacher
Marital Status: Married
Risk Factors: Recent childbirth (postpartum period)
Family history of depression (sister diagnosed)
High levels of stress from balancing work and family responsibilities
Limited social support due to living far from family
Previous Medical, Surgical, and Psychiatric History:
Medical History: Generally healthy, no chronic conditions
Surgical History: Cesarean section for the first child
Psychiatric History: No previous psychiatric diagnoses or treatments
Objective Data
Physical Exam Findings:
Vital Signs: BP 118/76 mmHg, HR 72 bpm, Temp 98.6°F
Weight: 135 lbs (10 lbs lost in the last month)
General Appearance: Appears fatigued, with poor eye contact and disheveled hair
Skin: No rashes or lesions; slightly pale
Neurological: Alert and oriented; no focal deficits noted
Mental Status Exam:
Appearance: Neglected grooming
Behavior: Cooperative but withdrawn; minimal engagement in conversation
Mood: Depressed with a flat aQect
Thought Process: Logical but slow to respond
Thought Content: No delusions or hallucinations; expresses feelings of being overwhelmed
Insight: Limited insight into her condition
Judgment: Fair; recognizes the need for help
Recommended Diagnostic Tests
PHQ-9 (Patient Health Questionnaire-9): To screen for and assess the severity of
depression in adults.
Complete Blood Count (CBC): To rule out anemia or other medical conditions contributing
to fatigue.
Thyroid Function Tests: To assess the function of the thyroid gland.
Comprehensive Metabolic Panel (CMP): To evaluate electrolyte levels and overall
metabolic health.
Urinalysis: To check for any underlying infections or issues that may contribute to mood
changes.
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INSTRUCTIONS-
i. Based on the information provided above, list your top three mental health
diQerential diagnoses.
ii. Choose the most likely diagnosis.
iii. Support your decision with APA scholarly sources that represent a logical link
between the above case study and article information.
Communicate with minimal errors in English grammar, spelling, syntax, and punctuation.
iv. Present information in a logical, meaningful, and understandable sequence that is
relevant to the discussion topic.
v. Good writing calls for the limited use of direct quotes. Direct quotes in
discussions are to be limited to one short quotation (not to exceed 10 words). The
quote must add substantively to the discussion.
vi. Reference Citation: Use current APA format to format citations and references
and is free of errors.
vii.
