Clinical Reasoning Cycle: Alison Case Study

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CLINICAL REASONING CYCLE
ALISON CASE STUDY
This paper intends to provide a reflection upon a case study of ‘Alison’ a 38-year-old single
mother of two, with a current working diagnosis of Clinical Depression. In consideration of her
current situation, financially she is not well off and is also struggling to perform her job. There
are significant stressors being feeling so low and also have two children who depend on her.
Moreover, her relationship is not really that good and is also significant that it is becoming a
major stressor to her. However, there are some protective factors include the fact that she has
supportive sisters.
There are many areas to assess as the aetiology of mental health issues has been linked to a range
of factors. As a clinician, you need to know what areas these are and the rationale for
incorporating them. The assessment of Alison requires a biopsychosocial approach. The
biopsychosocial approach involves looking into the person’s biological, psychological and social
factors (Atkins, Colville, & John, 2012). The three dimensions build to the fact that a person
suffers as a whole and not as isolated organs. A key feature of this is the mental status
examination (MSE), that is, a biopsychosocial approach cannot be complete without MSE
(Evans, Nizette, & O’Brien, 2017). In Alison's case, this was undertaken by the GP. A summary
of the findings was that her general appearance was that she was well kempt and dressed
decently. She, however, could not maintain direct eye contact. Her behaviour demonstrated
syndromes of unilateral spatial neglect. Cognitively she was... Her speech was spontaneous and
soft as the patient could relate the questions to answers that yield much useful information. The
thought process was logical and goal oriented. Thought content was devoid of any classical
delusional themes however contained cognitive distortions of derealization. Her affect was
dysphoric. Mood state was depressed and Perception indicates that there was no response to or
report of hallucinations and delusion. Her level of insight was normal with judgment being
normal.
By analysing the available data from this broad approach and more specifically from the MSE,
her diagnosis of Depression can be described by the DSM-5 as a persistent feeling of sadness and
hopelessness and lose interest in the activities which they usually or once enjoyed (Paris, 2013).
In a review of the risk assessment findings, she is currently feeling hopelessness and has lost