A 28-year-old female presents to your office stating that she is troubled by headaches and fatigue. She says that she always feels tired and can’t sleep well, often waking up early if she gets to sleep at all. She describes her headaches as dull, aching, and generalized. These symptoms began about three weeks ago and have been getting worse. She reports a lack of interest in her usual activities, even the ones that she used to enjoy. She also reports that she is missing work due to fatigue and inability to concentrate. Although both her children are in school, she is concerned that she is “losing them”. She is worried that she might have “something bad” because she has difficulty concentrating and is having frequent crying spells. She reports a loss of appetite, with a weight loss of 10 pounds in the last month.
The patient has no significant past medical or psychiatric history and takes no regular medications. However, she takes ibuprofen for headaches. She denies using alcohol or drugs. The patient is married, with two elementary school-age children.
Summarize the clinical case.
Create a list of the patient’s problems and prioritize them.
Which diagnosis should be considered
What is your rationale for the diagnosis
What differential diagnosis should be considered
What test or screening tools should be considered to help identify the correct diagnosis
What treatment would you prescribe and what is the rationale (consider psychopharmacology, diagnostics tests, referrals, psychotherapy, psychoeducation)
What standard guidelines would you use to assess or treat this patient
