e Objective
The client is a 29-year-old, Latino single male
referred by his primary care provider for a
psychiatric evaluation at an outpatient
... [Show More] clinic.
Client’s Chief Complaints:
“I think I might be depressed.”
History of Present Illness
The client reports increasingly depressive
symptoms with onset 3 months ago. He is
experiencing stress related to being unemployed,
financial strain and needing to sell his home quickly
because he cannot afford the mortgage. He reports
depressed mood, low energy, low motivation,
anhedonia, poor concentration, loneliness, low
selfesteem, hopelessness, and decreased appetite
with 12 lb. weight loss over the past month. He
reports difficulty falling and staying asleep due to
anxiety and restlessness, difficulty making decisions
and self-isolation. He endorses anxiety related to
the stressors reported above, as manifested by
restlessness, worry, and muscle tension. He reports
that his current mental state is impeding his ability
to apply for new employment and prepare his
home for the impending sale.
Past psychiatric history: no previous history, this is
the client’s first contact with a mental health
provider.
Past Medical History: childhood asthma, does not
use inhaler.
Family History
• Father is alive and well.
• Mother is alive, has anxiety “all her life”
One brother aged 24, alive and well
Social History
• Lives alone
• single
• does not have any friends
Physical Examination:
Height: 67″, weight: 200 lb.
General: Well-nourished male appears stated age
Mental status exam:
Appearance: appropriate dress for age and situation, well
nourished, eye contact poor, slumped posture
Alertness and Orientation: alert, fully oriented to
person‚ place‚ time‚ and situation,
Behavior: cooperative
Speech: soft, flat
Mood: depressed
Affect: constricted, congruent with stated mood
Thought Process: logical‚ linear
Thought content: Self-defeating thoughts, endorses thoughts
suggestive of low self-worth. No thoughts of suicide‚ self-harm‚
or passive death wish
Perceptions: No evidence of psychosis, not responding to internal
stimuli, reports auditory hallucinations.
Memory: Recent and remote WNL
Judgement/Insight: Insight is fair, Judgement is fair
Attention and observed intellectual functioning: Attention intact
for purpose of assessment. Able to follow questioning.
Fund of knowledge: Good general fund of knowledge and
vocabulary
Musculoskeletal: normal gait
NR 546 Week 5 Case Study
9.22 CCK
Primary diagnosis: Major Depressive Disorder, single episode, moderate with anxious distress (F32.1)
allergic to grass, perennial trees,
dust mites, and cockroaches.
NR 546 Week 5 Case Study
9.22 CCK
A. Select one drug to treat the diagnosis(es) or symptoms.
For this patient, I have chosen paroxetine (Paxil) for symptoms of depression
such as anhedonia, poor concentration, decrease appetite, poor concentration, low selfesteem, and low motivation along with the symptoms of anxiety including worry,
restlessness, muscle tension and difficulty falling asleep (Stahl, 2020; Stahl, 2021).
B. List medication class and mechanism of action for the chosen medication.
Paroxetine is a selective serotonin reuptake inhibitor (SSRI) it is most often
classified as an antidepressant (Stahl, 2020; Stahl, 2021). Paroxetine blocks serotonin
reuptake which boosts serotonin levels (Stahl, 2020). It also desensitizes serotonin
receptors, especially the serotonin 1A autoreceptors, this can presumably increase
serotonin neurotransmission; it also has mild anticholinergic actions and mild
norepinephrine reuptake blocking actions (Stahl, 2020). C. Write the prescription in
prescription format.
Date: 9/27/22
Patient name: Carlos Ruiz
DOB: 6/24/1993
℞: Paxil 20 mg tab
Sig: take one tablet (20 mg) by mouth daily
Disp: #14 (fourteen)
Refills: none
APRN, PMHNP-BC [Show Less]