A 38-year-old woman presents to the office with complaints of weight
loss, fatigue, and insomnia of 3-month duration. She reports that she has
been feeling gradually more tired and staying up late at night because
she can’t sleep. She does not feel that she is doing as well in her occupation
as a secretary and states that she has trouble remembering things.
She does not go outdoors as much as she used to and cannot recall the
last time she went out with friends or enjoyed a social gathering. She
feels tired most of the week and states she feels that she wants to go to
sleep and frequently does not want to get out of bed. She denies any
recent medication, illicit drug, or alcohol use. She feels intense guilt
regarding past failed relationships because she perceives them as faults.
She states she has never thought of suicide, but has begun to feel increasingly
Her vital signs and general physical examination are normal, although
she becomes tearful while talking. Her mental status examination is significant
for depressed mood, psychomotor retardation, and difficulty attending
to questions. Laboratory studies reveal a normal metabolic panel, normal
complete blood count, and normal thyroid functions.
➤ What is the most likely diagnosis?
➤ What is your next step?
➤ What are important considerations and potential complications of
The patient’s symptoms of weight loss, fatigue, insomnia, social withdrawal, and feelings of worthlessness suggest a possible diagnosis of major depression. The patient’s physical examination and laboratory studies do not reveal any physical illness causing her symptoms.
1. What is the most likely diagnosis?
The most likely diagnosis for the patient’s symptoms is major depression. Her symptoms meet the criteria in the DSM-5 for major depressive disorder, including depressed mood, loss of interest or pleasure, weight loss, insomnia, psychomotor retardation, feelings of guilt or worthlessness, and difficulty concentrating.
2. What is your next step?
The next step in management is to obtain a thorough psychiatric evaluation by a mental health professional. The patient should be referred to a psychiatrist or psychologist for further evaluation and treatment. The psychiatric evaluation should assess the severity of the depression, assess for suicidal ideation, and develop a treatment plan, which may include psychotherapy, pharmacotherapy, or both.
3. What are important considerations and potential complications of management?
Important considerations include the need for the patient to adhere to the treatment plan, which may be challenging for individuals with depression. Potential complications of management may include the risk of suicide, adverse effects of medication, and the possibility of relapse of symptoms. The patient should be closely monitored for any changes in symptoms, side effects of medication, and suicidal ideation. It is important for the patient to have regular follow-up appointments with mental health professionals to ensure optimal management of symptoms.
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