(2) discussion replies

1. Case Study Chosen #1: Mildred is a 45-year-old married female with three children. She presents to the clinic with complaints of fatigue and difficulty sleeping. She states she wants to get a good night’s sleep and is requesting a prescription to help her sleep. Mildred tells you she is awake off and on during the night, frequently thinking about her husband’s recent layoff from construction work and the effect this is having on the family. She lies down often during the day and has been so fatigued that she took some time off from work during the last two weeks. She is tearful at times during the visit and looks sad and anxious. On further discussion, she says she feels overwhelmed, helpless, and anxious. She tells you about an episode where she felt her heart beating rapidly, had difficulty catching her breath, felt she was going to have a heart attack, and became frightened until her husband was able to help calm her down. She is not eating as much as usual, and when she reads the newspaper, she does not remember what she has read.

Demographics: 45 y/o Female

SUBJECTIVE

• CC: “I have been having trouble sleeping, it has caused me a great amount of fatigue and I need something that keeps me asleep. My family has been greatly affected by my husband’s layoff leaving me anxious, overwhelmed, helpless and crying. I even experienced a heart-attack-like feeling and my husband had to calm me down.”

• HPI: 45 y/o female visiting the office this morning ? stress, helplessness, anxiety, difficulty concentrating and sleeping that has been going on for a few weeks. Pt states that the symptoms are constant. Pt symptoms are relieved by the comfort of her husband

• Past medical hx: Do you have any past medical hx?

• Past surgical Hx: Do you have any past surgical hx? If so, what are the dates of the surgeries?

• Family hx? Do you have any family history on either side (mother/father)?

• Current Medications: Are you currently taking any medications? Are you taking any OTC pain relievers, or OTC supplements?

• Allergies: Do you have any medication, food, or chemical allergies? If so, what is the reaction?

• Immunization hx: Do you currently have all of your up-to-date immunizations including flu, covid-19 + boosters?

• Health Maintenance: When was your last dental, eye, physical examination?

• Social HX: Are you currently employed? What are your eating habits? Do you smoke tobacco products, drink alcohol, or use illicit drugs? Where are you currently living? Who do you live with? Are you married, single? Are you sexually active?

ROS

General: Are you having any malaise, weakness, fever, chills. Have you noticed weight gains/losses of >20 lbs over the last 6 months.

Neurological: Have you noticed unusual headaches, history of head injury or loss of consciousness, lightheadedness, dizziness, vertigo. Have you noticed any numbness of a body part or weakness on one side of the body? Any feeling of pins and needle sensation, abnormal movements, or seizure disorder. Any hx of previous strokes, seizures or neurological disorders.

Psychiatric/mental status: Pt reports difficulty concentrating and change of memory. Do you have any anxiety or depression? Any difficulty sleeping, persistent thoughts or worries, decrease in sexual desire, abnormal thoughts, visual or auditory hallucinations? Any hx of psychosis or schizophrenia?

Cardiovascular: Pt reports chest discomfort, heaviness or tightness. Pt reports an abnormal heartbeat or palpitations. Have you had any SOB, or had to sleep elevated on 2 pillows or more? Have you noticed swelling to feet, or passing out or nearly passing out? Any hx of heart attack/heart failure.

Respiratory: Have you noticed a cough? phlegm production, coughing up blood, wheezing, sleep apnea, exposure to inhaled substances in the workplace or home? Any exposure to TB or travel outside of the country? Any hx of asthma, COPD/emphysema or any other chronic pulmonary disease?

Gastrointestinal: Ask about changes in appetite, nausea, vomiting, and bowel movements

Musculoskeletal: Pt reports muscle/joint pain. Have you noticed any back/neck pain? Have you had any recent accidents or injuries? Any physical disability or condition that limits activity or ADLs?

OBJECTIVE

General:

• Take all VS of patient: BP, HR, RR, Weight, Height, BMI

Physical Exam Elements:

• General: Vital signs stable, in no acute distress. Alert, well developed and well nourished.

• Neuro: Assess cranial nerves, DTRs, sensation to light touch, and motor/sensory deficits.

• Respiratory/chest: Auscultate the lungs for any respiratory abnormalities.

• Cardiovascular:Auscultate the heart for any Cardiac abnormalities.

• Psych: Pt reports memory change. Assess if the patient is A&OX3. Assess mood/affect/judgment, and insight during visit. Perform a mini-mental exam.
• Gastrointestinal: Assess bowel sounds. Tenderness, masses, hernias.

• Musculoskeletal: Assess gait, and station. Assess ROM. Assess muscle strength and tone and arm swing.

POC Testing (any Point of Care (POC) testing specifically performed in the office):

• EKG

ASSESSMENT

Working Diagnosis:

Major depressive disorder with anxious distress – ICD – F41.2

Mixed anxiety-depressive disorder (MADD) is a new diagnostic category defining patients who suffer from both anxiety and depressive symptoms of limited and equal intensity accompanied by at least some autonomic features. Patients do not meet the criteria for specific anxiety or depressive disorders. The emergence of the symptoms is independent of stressful life events. Mildred is going through a stressful time in her life.

(NIH, 2022).

• Feeling persistently worried.
• Feeling flat or hopeless.
• Thinking negatively.
• Feeling unmotivated.
• Feeling irritable.
• Having trouble concentrating.
• Being unable to enjoy the things you used to.

Differential Diagnosis:

Generalized Anxiety Disorder -ICD- 10 F41.1

GAD means that you are worrying constantly and can’t control the worrying. The symptoms of GAD can happen as a side effect of a medicine or substance use. It can also be related to medical conditions, such as hyperthyroidism, that increase hormones. This can make the body respond more excitable. GAD can be triggered by family or environmental stress. Chronic illness and disease can also trigger GAD (Hopkins, 2023).

• Trouble falling or staying asleep
• Lightheadedness
• Trouble breathing
• Tense muscles
• Irritability

• Trembling

• Twitching
• Headaches
• Sweating
• Hot flashes
• Nausea

(Hopkins, 2023).

Panic Disorder – ICD – 10: F41.0

Panic disorder is an anxiety disorder that involves multiple unexpected panic attacks. A main feature of panic disorder is that the attacks usually happen without warning and aren’t due to another mental health or physical condition. There’s often not a specific trigger for them.

(Cleveland Clinic, 2022).

• Racing heart.
• Chest Pain
• Nausea
• Tingling/Numbness in fingers/toes
• Difficulty breathing, such as hyperventilation.

• Trembling or shaking.
• Chills
• Sweating.

PLAN

Diagnostic studies:

• Sending patients out for the following w/ orders.

Lab: CBC, CMP, Thyroid function tests including TSH and thyroid hormones, troponin levels

Treatment: Lexapro 10 mg PO QD (30 tabs) 1 refill

Selective serotonin reuptake inhibitors (SSRIs) are a class of medications most commonly prescribed to treat depression. They are often used as first-line pharmacotherapy for depression and numerous other psychiatric disorders due to their safety, efficacy, and tolerability (NIH, 2023).

Referrals:

• Psychiatric or mental health follow-up care and to support groups.
• Refer to a cardiologist due to the cardiovascular symptoms she presented such as her heart beating rapidly, having difficulty catching her breath, feeling she was going to have a heart attack.

Education:

• Psychotherapy
• Breathing techniques
• Review possible triggers to stay away from
• Decrease caffeine intake
• Medication adherence, and education on SSRIs (need to continue to take- 2 weeks to kick in)
• Encourage the patient to make positive lifestyle changes, including regular exercise, a balanced diet, adequate sleep, and stress management techniques.
• Discuss the importance of seeking support from family, friends, or support groups.
• Teach stress reduction techniques, such as deep breathing, mindfulness, and progressive muscle relaxation.

Health maintenance:

• Dental exam (every 6 months)
• Eye exam (yearly)
• Physical exam (yearly)
• Flu shot (yearly)
• Mammogram (q10 years- unless medical hx)
• PAP (q3 years)

2. Case Study Chosen: Kylie, a 24-year-old female patient, comes to your office for a refill of her allergy medication. Before going into the room, you note that her Patient Health Questionnaire – Depression (PHQ-9) score is 20, and that she is not currently on any medication for depression. When you enter the room, you notice that Kylie is easily startled, and she is sitting in the corner of the room very close to the wall.

Demographics:

Age- 24

Gender- Female

SUBJECTIVE

• CC: “I need a refill on my allergy medication”
• HPI: Kylie is a 24 year old that presents with a chief complaint of requesting a refill for her allergy medication. Before entering the room, it was noted that her Patient Health Questionnaire – Depression (PHQ-9) score is 20, and she is not currently on any medication for depression. Upon entering the room, she appears easily startled and is sitting in the corner of the room very close to the wall.

• Past medical hx: Do you have any past medical hx?

• Past surgical Hx: Do you have any past surgical hx? If so, what are the dates of the surgeries?

• Family hx? Do you have any family history on either side (mother/father)?

• Current Medications: Are you currently taking any medications? Are you taking any OTC pain relievers, or OTC supplements?

• Allergies: Do you have any medication, food, or chemical allergies? If so, what is the reaction?

• Immunization hx: Do you currently have all of your up-to-date immunizations including flu, covid-19 + boosters?

• Health Maintenance: When was your last dental, eye, physical examination?

• Social HX: Are you currently employed? What are your eating habits? Do you smoke tobacco products, drink alcohol, or use illicit drugs? Where are you currently living? Who do you live with? Are you married, single? Are you sexually active?

• Subjective: (What questions will you ask? Must be listed by System, ONLY as it pertains to Chief Complaint/HPI. Should NOT be all systems or full head to toe unless pertinent).
  • Cardiovascular
    • Any chest pain?
    • Have you had palpitations?
    • Any swelling?
    • Are you feeling tired?
    • Family history we should know of?
  • Pulmonary
    • Any shortness of breath?
    • Do you have a cough?
    • Any wheezing or chest pain?
    • Have you coughed up any blood or mucus?
  • HEENT
    • Is your nose runny?
    • How long have you had allergies?
    • What are your symptoms?
    • Have you had any reactions to medications?
    • Any triggers?
    • What relieves your allergies?
  • Psyche
    • How is your sleep?
    • Do you feel safe?
    • Any changes in your daily routine?
    • Do you feel like hurting yourself or others?
    • Do you have a plan?
    • Do you feel anxious or worried?
    • Any significant life events?
    • Loss of interest?

OBJECTIVE

General:

• Vital Signs
  • BP: 136/88
  • HR: 98
  • RR: 20
  • Weight:127
  • Height: 5’3
  • BMI: 24.3
• Physical Exam Elements: (Must be listed by System, ONLY as it pertains to Chief Complaint/HPI. Should NOT be all systems or full head to toe unless pertinent.)
  • General: clean, alert and oriented x4
  • Cardiovascular: S1 and S2 sounds even and clear, WNL blood pressure
  • Respiratory: No labored breathing, no crackles, clear and even breaths
  • HEENT: rhinitis noted, no difficulty breathing, able to clear throat, no coughing or airway obstruction.

• POC Testing (any Point of Care (POC) testing specifically performed in the office):
  • None performed during this office visit

ASSESSMENT

• Working Diagnosis: Depressive Disorder ICD-10: F32.9
  • Depressive disorder is a common mental disorder. It involves a depressed mood or loss of pleasure or interest in activities for long periods of time. Depression is different from regular mood changes and feelings about everyday life. Depressed mood, anhedonia, fatigue, hopelessness, hypersensitivity, irritability, social withdrawal (Navneet and Abdijadid, 2022).
• Differential Diagnosis:
  • Social Anxiety- F40.10: Social anxiety disorder is an intense, persistent fear of being watched and judged by others. This fear can affect work, school, and other daily activities. It can even make it hard to make and keep friends (Social Anxiety Disorder, 2022). A person with social anxiety disorder feels symptoms of anxiety or fear in situations where they may be scrutinized, evaluated, or judged by others.
  • Generalized Anxiety Disorder- F41.1: Generalized anxiety Disorder means that you are worrying constantly and can’t control the worrying.usually involves a persistent feeling of anxiety or dread that interferes with how you live your life. It is not the same as occasionally worrying about things or experiencing anxiety due to stressful life events (National Institute of Mental Health, 2022).

PLAN

• Diagnostic studies:
  • CBC with diff
  • Thyroid Function Test
  • CMP
• Treatment:
  • Sertraline 50mg daily PO for depression

• Referrals:
  • Psychiatrist
  • Psychologist
• Education:
  • Explain that her medication is an SSRI and takes a few weeks to notice a difference. Please take medication as prescribed and we can taper off if needing to discontinue.
  • Contact us if you experience SI, thoughts harm to self or others, or are experiencing side effects of medication that affect your daily living.