You are working in an outpatient office. J.B. is a 38 year-old married female who has come in for an initial evaluation. She has a full-time managerial job at a law firm and is a mother to 3 young children. Balancing work and family life has been challenging but until recently she thought she was handling it. Her husband, who works full-time as well, is involved at home and is proactive in sharing the workload. For the past 2 months she has felt “debilitating” fatigue but ironically she is having trouble sleeping at night, only getting 3-4 hours most nights. She has called in sick to work three times in the past three weeks because of feeling so fatigued and stressed. J.B. is having trouble concentrating and is finding that work is piling up at her job and at home, which is uncharacteristic and this has led to feelings of shame and worthlessness. In addition, her appetite is diminished and she has lost 6 pounds in the last two weeks. She is feeling overwhelmed and thinks something must be wrong with her and is now constantly worrying about never feeling like herself again. Her past medical history includes three pregnancies/three healthy deliveries and some feelings of withdrawal/sadness after her first baby. She has never sought mental health treatment before now.
1. What other assessment information would you need to know from J.B.?
2. Are there any assessment tools/questionnaires that you would use?
3. Any test/diagnostic labs or referrals?
4. What is your proposed primary diagnosis and at least two differentials? (Explain how you would rule out your differentials and support your working diagnosis).
5. Would you start any medications and if so what/how/when? (include a drug/dose for the potential mental health dx).
6. When would you see this client back? What non-medication interventions would you recommend? What patient education/health promotion would you include?
7. Use at least 2 current evidence-based outside sources to support your discussion and respond to two of your peers.
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