Assessment
- Major Depressive Disorder (ICD 10 code F33.0): This condition if frequently associated with such problems as issues with mood and self-esteem (Armstrong, 2011). Moreover, this illness is especially problematic at this age because of increased risks of morbidity. Changes in behavior are also frequently noticeable. This primary diagnosis is reasonable in this situation because such symptoms as issues with sleep, somnolence, and fatigue have been noted (Armstrong, 2011).
- Plan for Major Depressive Disorder: Rx: Wellbutrin SR sustained-release 150mg orally daily for two months Disp # 30 Refill # 2. It may be necessary to increase the dosage depending on the symptoms (Armstrong, 2011).
- Additional Diagnostic Tests: It is necessary to evaluate the risk of suicide in this case. Moreover, the assessment will be focused on such aspects as suicidal thoughts and if an individual has demonstrated such behavior in the past. Moreover, The Geriatric Depression Scale should be used to determine the severity of this problem (Seller & Symons, 2012).
- Education: The information regarding treatment options that are available should be provided to ensure that the patient will be able to make reasonable decisions, and will have an understanding of what side effects may be expected. Moreover, he should be encouraged because many individuals think that recovery is not possible (Armstrong, 2011).
- Referrals: Need to refer to a mental health professional may be considered if the condition of the patient worsens and treatment is not effective (Armstrong, 2011).
- Follow up: Diagnosis may have to be reconsidered if there is no noticeable improvement. Moreover, the follow-up should be focused on the prevention of relapse. The patient should be advised to continue taking the same dose of the medicine if the treatment has been successful for 4-9 months (Armstrong, 2011).
- Somatic Symptom Disorder (ICD 10 code F45.0): Patients that have to deal with this condition suffer from a variety of symptoms that cannot be explained with testing most of the time (Kurlansik & Maffei, 2016). Moreover, they are frequently worried about such issues. The differential diagnosis is appropriate in this case because the patient is presented with a broad range of symptoms as reduced appetite, problems with sleep, fatigue, and others. Testing did not show any significant abnormalities. Also, it is evident that the patient has some issues with balance because he required help from his neighbor (Kurlansik & Maffei, 2016).
- Plan for Somatic Symptom Disorder: Rx: Amitriptyline 10mg orally t.i.d. for 3 weeks Disp # 28 Refill # 4. Such symptoms as fatigue, issues with sleep are improved most of the time with the use of this medicine (Kurlansik & Maffei, 2016).
- Additional Diagnostic Tests: A use of the Patient Health Questionnaire and Somatic Symptom Scale is recommended in such cases (Kurlansik & Maffei, 2016).
- Education: It is imperative to provide an explanation of this condition to the patient. Moreover, he should be advised to avoid activities that would be stressful and could complicate the treatment.
- Referrals: It may be necessary to refer the patient to a psychiatrist if it is necessary (Kurlansik & Maffei, 2016).
- Follow up: Regular visits should be considered to keep track of the progress and to identify if no complications are introduced. Moreover, it is recommended to establish relationships with a patient and his relatives to improve the outcome. Also, unnecessary tests should be avoided because they may worsen the problem (Kurlansik & Maffei, 2016).
References
Armstrong, C. (2011). APA releases guideline on treatment of patients with major depressive disorder. American Family Physician, 83(10), 1219-1227.
Kurlansik, S. L., & Maffei, M. S. (2016). Somatic symptom disorder. American Family Physician, 93(1), 49-54.
Seller, R., & Symons, A. (2012). Differential diagnosis of common complaints (6th ed.). Philadelphia, PA: Elsevier Saunders.