Reference no: EM133452224
TREATMENT PLANNING
Review the case vignette below and draw up a treatment plan based on the information provided in the case study. You must write a treatment plan as if you interviewed the client for a fist session. Your treatment plan should address among other aspects:
What the most likely diagnosis is;
List the symptoms and reasons why you ascribe this diagnosis;
The most appropriate treatment;
Goals and objectives for at least 2 problems;
What other referrals will you consider and why?
CASE:
Chief Complaint
A 27-year-old woman 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. 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. She also reports that she is missing work due to fatigue and inability to concentrate. Although her two children are both in school, she is concerned that she is not spending quality time with them. She is worried that she might have "something bad" because she has difficulty concentrating and is having frequent crying spells. She reports not sleeping well and a loss of appetite, with a weight loss of 10 pounds in the last month.
She is cooperative, alert, oriented; no delusions or hallucinations, and her thoughts are goal-directed and logical. During the interview, the patient suddenly bursts into tears. She tells you that she has been feeling sad almost all the time. She also tells you that her husband is in Iraq for his second tour of duty. She states that her thoughts are full of worries, with feelings of hopelessness and worthlessness. She denies current suicidal ideation.
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.