Diagnosis:
Major Depressive Disorder (MDD)
Treatment Plan and Notes:
J.D. is a 69-year-old male patient who presented himself to the clinic accompanied by his 25-year-old daughter. J.D. reports that he has been feeling that he has so far done nothing meaningful with his life and has a deep sense of unworthiness. He notes that he easily feels offended and is persistently in low moods. His daughter reports that J.D. has been persistently moody for the past month and has always grumpy for over three months.
J.D. appears openly sad and despondent and has visibly low energy. He had a flat affect, and his speech was quite sluggish. He reports that he is finding it difficult to fall asleep. His daughter reports that J.D. is increasingly refusing to eat, as he notes he has no appetite. Further analysis of the patient’s note shows that his psychomotor capacities are retarding while he is mostly lost in thought and with poor concentration throughout the evaluation. Physical examination did not find any physical abnormalities of concern. A review of J.D.’s symptoms and the health and medical history that was reported against the DSM-5 TR fulfil the diagnostic criteria for Major Depressive Disorder (MDD). The patient was diagnosed with MDD.
J.D.’s treatment will include both pharmacological and non-pharmacological therapy. Sertraline was prescribed. J.D. will take sertraline 50 mg once daily, majorly in the evening. The dosage will be adjusted based on the progress of the symptoms but should not exceed 200 mg per day. A referral to a mental health therapist is made as J.D. will need to be put under cognitive-behavioural therapy (CBT) two times a week for the next four weeks to improve his negative self-thinking and improve his ability to cope. J.D.’s daughter was educated on medication safety, managing her father’s symptoms, and any unintended drug outcome. A safety assessment will also be required to be concluded in the next seven days after J.D. starts using his medications to ensure he has a safe environment for recovery and that he does not pose a threat to himself and the other family members. The next follow-up appointment is scheduled after the next 14 days.