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Case Summary #1: Depression
Case Summary #1: Depression
GENERAL DATA:
This is a case of J.R., 30 years old, Male, Filipino, Roman Catholic, Married with two kids,
Residing at 27 kundiman Street, Tarlac City, her wife is working in a human resources
department of a large manufacturing firm. He was admitted for the first time in NCMH on
October 19, 2020.
CHIEF COMPLAINT:
He finds it hard to go back to work because he feels a strong emotional jolt every time he signs
his signature it was like him signing her daughter's death warrant. He feels angry with medical
staff, although he says that they did nothing wrong. He has lost his appetite, his sleep is poor
and he is drinking more alcohol than usual. He feels a general lack of energy and says that he
has difficulty enjoying things any more. Prior to his daughter’s operation he was happy,
although understandably concerned about his daughter’s health. He also regularly went out
with friends followed by drinks and a meal. He could laugh and enjoy himself at this time. He
has no history of depression or psychiatric or psychological problems.
MEDICATION HISTORY:
FAMILY HISTORY:
SOCIAL HISTORY:
He is living a sedentary lifestyle and prefers to be alone most of the time. He is not able to
GENERAL APPEARANCE:
Male, 30 years old who looks older than age. He is well dressed in chinos and an iron ironed
open neck shirt. Not well groomed with slightly messy hair and beard with not trimmed
recently. His eye contact is good. He is tall and looking weak staying in sitting position. He looks
sad but awake and alert.
BEHAVIOUR:
He feels emotional jolt (every time he signs remembering the consent papers he signed) He
describes being tearful about once per week. Also he feels general lack of energy. He looks
depressed and sad but cooperates. he is with low mood and self-confidence. He expresses
himself in low voice. He shows restricted range of affect. His mood is congruent with affect.
THOUGHT PROCESS:
His thoughts are mostly normal in speed , flow and content but some instances he shows
illogical thoughts such as He was feeling angry towards medical staff unnecessarily and he was
feeling guilty when he laughs. He is not always coherent but most of his thoughts are goal
directed.
THOUGHT CONTENT:
COGNITIVE:
Patient can feel the difference in his thoughts and also the reason for it which is his baby girl's
death. Also he can understand the impact of it on his daily functioning such as work life and
other daily routines.
JUDGEMENT:
The patient does cooperate with psychiatrist. He is aware of his behaviour and that’s why he
comes to seek the help of physiatrist.
DIAGNOSIS:
DEPRESSION
Diagnostic Criteria:
Associated symptoms
Somatic symptoms
Mild depression
Moderate depression
Severe depression
DIFFERENTIAL DIAGNOSIS:
Grief
MANAGEMENT:
Antidepressant medications
Psychotherapy
CASE DISCUSSION:
I.DEFINITION
Depression (major depressive disorder) is a common and serious medical illness that negatively
affects how you feel, the way you think and how you act. Fortunately, it is also treatable.
Depression causes feelings of sadness and/or a loss of interest in activities you once enjoyed. It
can lead to a variety of emotional and physical problems and can decrease your ability to
function at work and at home.
II.SYMPTOMS
III.CAUSES
• Conflict. Depression in someone who has the biological vulnerability to develop depression may
result from personal conflicts or disputes with family members or friends.
• Death or a loss. Sadness or grief from the death or loss of a loved one, though natural, may
increase the risk of depression.
• Genetics. A family history of depression may increase the risk. It's thought that depression is a
complex trait, meaning that there are probably many different genes that each exert small
effects, rather than a single gene that contributes to disease risk. The genetics of depression,
like most psychiatric disorders, are not as simple or straightforward as in purely genetic diseases
such as Huntington's chorea or cystic fibrosis.
IV.RISK FACTORS
Depression carries a high risk of suicide. Suicidal thoughts or intentions are serious. Warning signs
include:
A sudden switch from sadness to extreme calmness, or appearing to be happy
Always talking or thinking about death
Clinical depression (deep sadness, loss of interest, trouble sleeping and eating) that gets
worse
Taking risks that could lead to death, such as driving through red lights
Making comments about being hopeless, helpless, or worthless
Putting affairs in order, like tying up loose ends or changing a will
Saying things like "It would be better if I weren't here" or "I want out"
Talking about suicide
Visiting or calling close friends and loved ones
VI.PREVENTION
Physical exercise can help treat depression, but it’s best to exercise regularly. To get more exercise, you
can:
• Join a sports team or studio (like yoga or kickboxing), where you’ll be part of a community in
addition to being active.
• Take the stairs instead of the elevator.
• Make it a habit: This is the best way to maintain the fitness level that is most effective in
preventing depression.