Case Study Topic-Human papillomavirus (HPV) (Women's Health)

Hello Dr. L and class

The area on the APEA predictor exam that I scored the lowest on was in Psychiatry with an 80%. I am not at all surprised because it has been a weakness of mine, and I find its research very challenging.

First, let’s define psychiatry: It is the branch of medicine focused on the diagnosis, treatment and prevention of mental, emotional and behavioral disorders (Falissard, Monegat, & Harper, 2017).

The case presenting below will focus on some of the most common types of mental disorders or illnesses seen in the primary care setting.

Case Presentation :

S: Subjective Data

Chief Complaint (CC): AA is a 40-year-old Caucasian female who presents to the clinic with a chief complaint of feeling sad, anxious, cries without any explanation every day, has no interest or pleasure in activities and is having trouble sleeping at nights.

History of Present Illness (HPI): AA is a 40-year-old Caucasian female who presents in the clinic with a chief complaint of feeling sad, fatigue, anxious, cries without any explanation every day, has no interest or pleasure in activities and is having trouble sleeping at nights. She states that she is awake almost every night worrying and having many thoughts such as not being a good wife to her husband and stated that she hardly does anything with him. A.A. states that she has been feeling this way for about a month now and has decided to seek help.

Past Medical History (PMHx): Denies

Medications: Multivitamin daily

Allergies: None

Family History (FHx): Mother-Depression. Father-HTN.

Social History (SHx): She lives with her husband of 10 years in a modest home and neighbourhood. She reports a decrease in sexual activity. Denies smoking or illicit drug use. Reports alcohol use occasionally. Reports that she stays in bed most of the day. She is a high school graduate and reports no interest in furthering her education. She is currently unemployed, but her husband has his own auto mechanic business. She reports no children. She reports having a sister who lives close by, and she stated that she used to enjoy spending time with her and her two kids where they would exercise, go shopping together and cook dinner.

Immunizations: Reports as being up to date

Review of Systems (ROS):

Constitutional: Negative for fever, chills, night sweats, reports a 5 lbs. weight loss

Respiratory: Negative for cough, shortness of breath, hemoptysis and wheezing, breathing fast

Cardiovascular: Negative for chest pain, orthopnea, edema, admits occasional palpitation

GI/GU: Negative for heartburn, constipation, dysuria, urgency, frequency, hematuria

Skin: Negative for itching, sores, nail changes and rash

Hematologic/Lymphatic: Negative for bleeding problems, blood clots and easy bruising

Musculoskeletal: Negative for myalgias, back pain, joint pain/swelling and falls

Neurological: Negative for dizziness, tingling, tremors, sensory change, seizures and headaches

Behavior/Psyche: Admits feeling sad, anxious, admits occasional fatigue, crying every day, no interest or pleasure in activities and having trouble sleeping at nights. Negative for drug abuse

Endocrine: Negative for heat/cold intolerance, excessive thirst

Allergic/Immunologic: Negative for anaphylaxis, angioedema, asthma

Objective (O):

Physical Exam:

BP 110/62: Pulse 103: Temperature 96.4: RR 24: Sp02 100%: Height 5’10”: Weight 140 pounds.

General Appearance: Alert, cooperative, in no distress, appears stated age, conversant, pleasant, depressed mood and anxious and appears fatigued

HEENT: Normocephalic, without obvious abnormality, atraumatic, PERRL, conjunctiva/corneas clear, EOM’s intact in both eyes, ears normal, no discharge or erythema, nares normal, septum midline, mucosa pink and moist, no drainage or sinus tenderness, lips, mucosa normal, and tongue with no deviation, neck supple, symmetrical, trachea midline, thyroid not enlarged, no tenderness, mass or nodules, no JVD

Back: Symmetrical, normal curvature, ROM normal, no CVA tenderness

Cardiovascular: Tachycardic, S1, S2 normal, no murmurs or rub or gallop, Palpitation

Lungs: Clear on auscultation bilaterally, tachypneic, no wheeze, rales or rhonchi

GI/GU: Abdomen soft, non-tender, non-distended, bowel sounds active in all four quadrants, no masses, no hernias, no organomegaly, voiding freely, genitalia deferred

Musculoskeletal: Moves all extremities, 5/5 strength, good ROM, no cyanosis or edema, pedal and femoral pulses intact and asymmetrical, good capillary refill

Skin: Normal temperature, tone, texture and turgor, no induration, no rash, lesions or scars

Lymph nodes: Cervical, supraclavicular and axillary nodes normal

Neurologic: Strength normal, sensation intact, No focal sensory deficits, CN’s intact, DTR’s intact and symmetrical

Psychiatric: Depressed mood and affect, alert and oriented x 3, intact judgement and insight, excessive crying, insomnia and social isolation

Associated risk factors/demographics as they are related to the chief complaint: 1 in 5 adults in the United States have been plagued by major depressive disorder (MDD) (Trivedi et al., 2019). Major depression is frequent and is a curable mental ailment categorized by a fluctuation in one’s mood, mental and bodily symptoms for more than a 2-week interval. The evidence shows that 10.4% of women are two times more than expected to have depression versus men at a rate of 5.5%. (Centers for Disease Control and Prevention, 2018).

Three common differential diagnoses represented by the CC including pathophysiology and rationale:

Major Depressive Disorder (MDD): Depression affects an estimated one in 15 adults (6.7%) in any given year (American Psychiatric Association, 2017). MDD is one or more major depressive episodes (MDE) and the lifetime absence of mania and hypomania (Uher, Payne, Pavlova, & Perlis, 2014).

Norepinephrine (NE) is recognized as having an important part in the pathophysiology of major depressive disorder. From one’s clinical experience, NE primary’s purpose is that of a neurotransmitter that balances and sends signal back and forth to nerve cells. On the other hand, Serotonin also has major influences on feelings and behavior and…has been involved in problems with sleep, appetite, libido, mood, and anxiety (McCrae, & Khan, 2014). The rationale is based on AA’s presenting s/s. Once these chemicals are low, it causes low levels in mood, behavior and the individual’s overall wellbeing.

AA meets criteria for MDE based on the Diagnostic and Statistical Manual of Mental Disorders fifth edition (DSM-5) (Uher, Payne, Pavlova, & Perlis, 2014). She is exhibiting s/s such as excessive crying, insomnia, depressed mood, anxiety and loss of interest or pleasure (anhedonia) for more than two weeks.

General Anxiety Disorder (GAD): Is a mutual mental disorder and is frequently tackled in the primary care setting. The cause of GAD is not effectively comprehended (Locke, Kirst, & Shultz, 2015). From one’s experience, patients usually present with s/s such as excessive worrying, unwanted thoughts, restlessness, trouble falling asleep and palpitations. The reason is that AA is showing all the signs of GAD.

Hypothyroidism: Hypothyroidism is a common endocrine disorder resulting from deficiency of thyroid hormone (Orlander, Varghese, & Freeman, 2018).

This is one type of endocrine disorder which creates an imbalance in hormones and causes symptoms such as fatigue, depression, mood changes, and sleep disruptions. Endocrine glands are responsible for making hormones that sends messages throughout the body (NIH, 2017). There are a few main glands such as pituitary, thyroid and adrenal glands just to name a few. These hormones affect body processes such as one’s disposition and how your body is working sexually. The reason for this diagnosis is the patient’s lack of interest in sex, fatigued and her mood.

Discuss how the three differential diagnoses differ from each other in: occurrence, pathophysiology and presentation:

In researching the occurrence, pathophysiology and presentation of MDD, GAD and Hypothyroidism, it is well documented that the rate of all three diagnoses are very common, complaints often can be mundane and very frequent amongst women. The pathophysiology is different in all disorder especially with MDD. Depression has been a difficult one to explain due to its characterization based on direct patient observation and the multiple medical conditions associated with it. Evidence points to an intricate communication between neurotransmitter readiness and receptor control and their understanding (Halverson, & Bienenfeld,2019). Its presentation can mimic GAD and Hypothyroidism such as fatigue, irritability, insomnia and changes in one’s mood. Depression and GAD are both central nervous system (CNS) chemical imbalances. Anxiety disorders differ from normal feelings of nervousness or anxiousness and involve excessive fear or anxiety (APA, 2017). GAD’s pathophysiology as defined by Bhatt, Baker, & Jain (2018) norepinephrine, serotonin, dopamine, and gamma-aminobutyric acid (GABA) in the CNS are the key mediators of the symptoms of anxiety disorders leading to its presentation such as palpitation, feeling dizzy and shortness of breath. On the other hand, the pathophysiology of Hypothyroidism is regulated by thyroid hormone secretion, and localized illness of the thyroid gland that ends in decreased thyroid hormone creation is the highest cause of hypothyroidism. Its presentation varies and are like some of the above disorders such as cold intolerance, depression, fatigue, loss of energy, unable to concentrate and mental impairment (Orlander, Varghese, & Freeman, 2018).

Relevant testing required to diagnose/evaluate severity of the three differential diagnoses: Both research and experience in the clinical setting have indicated that talking with the patients, conducting a H&P along with the depression screening known as Patient Health Questionnaire-9 (PHQ-9) and at times, obtaining blood test (to rule out other medical problems) will be a conclusive diagnosis for MDD. As for GAD, there is no clear-cut testing. The most important thing is to see your doctor to ensure that there are no other physical predicament triggering the symptoms (APA, 2017). Lab testing such as TSH levels and ultrasonography of the neck and thyroid can be used to detect nodules and infiltrative disease (Orlander, Varghese, & Freeman, 2018).

Review of relevant National Guidelines related to the Diagnosis and Diagnostic testing for these diagnoses:

For the patients with MDD, the APA’s Practice Guideline suggest completing a psychiatric assessment. A complete diagnosis of depression should address the following: HPI, psychiatric history, general medical history and all medications (APA, 2017). 

The GAD-7 and GAD-2 questionnaires are used for identifying anxiety disorders (Plummer, Manea, Trepel, & McMillan, 2016). There is no diagnostic testing required.

There is only a serum thyrotropin that is the single best screening test for primary thyroid dysfunction for many outpatient clinical situations (Garber et al., 2012).

References

American Psychiatric Association. (2017). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

Bhatt, N. V., Baker, M. J., & Jain, V. B. (2018). Anxiety Disorders. Retrieved from https://emedicine.medscape.com/article/286227-overview#a4. Medscape

Centers for Disease Control and Prevention. (2018). Prevalence of depression among adults aged 20 and over: United States, 2013-2016. National Center for Health Statistics (NCHS) Data Brief, (303), 1-8. Retrieved from https://www.cdc.gov/nchs/products/databriefs/db303.htm

Falissard, B., Monégat, M., & Harper, G. (2017). Psychiatry, mental health, mental disability: time for some necessary clarifications. European Child & Adolescent Psychiatry, 26(10), 1151–1154. https://doi-org.chamberlainuniversity.idm.oclc.org/10.1007/s00787-017-1037-4

Garber, J. R., Cobin, R. H., Gharib, H., Hennessey, J. V., Klein, I., Mechanick, J. I., ... & Woeber for the American Association of Clinical Endocrinologists and American Thyroid Association Taskforce on Hypothyroidism in Adults, K. A. (2012). Clinical practice guidelines for hypothyroidism in adults: cosponsored by the American Association of Clinical Endocrinologists and the American Thyroid Association. Thyroid, 22(12), 1200-1235.

Halverson, J. L., & Bienenfeld, D. (2019). Depression. Retrieved from https://emedicine.medscape.com/article/286759-overview#a3. Medscape

Locke, A. B., Kirst, N., & Shultz, C. G. (2015). Diagnosis and management of generalized anxiety disorder and panic disorder in adults. American Family Physician, 91(9), 617–624. Retrieved from https://search-ebscohost-com.chamberlainuniversity.idm.oclc.org/login.aspx?direct=true&db=mdc&AN=25955736&site=eds-live&scope=site

McCrae, N., & Khan, E. (2014). Shooting the messenger: the neurobiology of depression. British Journal of Neuroscience Nursing, 10(4), 185–190. Retrieved from https://search-ebscohost-com.chamberlainuniversity.idm.oclc.org/login.aspx?direct=true&db=ccm&AN=107816662&site=eds-live&scope=site

National Institutes of Health (NIH). (2017). Endocrine diseases. Retrieved from https://medlineplus.gov/endocrinediseases.html. MedlinePlus

Orlander, P. R., Varghese, J. M., & Freeman, L. M. (2018). Hypothyroidism. Retrieved from https://emedicine.medscape.com/article/122393-overview. Medscape

Plummer, F., Manea, L., Trepel, D., & McMillan, D. (2016). Screening for anxiety disorders with the GAD-7 and GAD-2: a systematic review and diagnostic metaanalysis. General hospital psychiatry, 39, 24-31.

Trivedi, M. H., Jha, M. K., Kahalnik, F., Pipes, R., Levinson, S., Lawson, T., … Greer, T. L. (2019). VitalSign6: A primary care first (PCP-First) model for universal screening and measurement-based care for depression. Pharmaceuticals (14248247), 12(2), 71. https://doi-org.chamberlainuniversity.idm.oclc.org/10.3390/ph12020071

Uher, R., Payne, J. L., Pavlova, B., & Perlis, R. H. (2014). Major Depressive Disorder in Dsm-5: Implications for clinical practice and research of changes from Dsm-Iv. Depression & Anxiety (1091-4269), 31(6), 459. Retrieved from https://search-ebscohost-com.chamberlainuniversity.idm.oclc.org/login.aspx?direct=true&db=edb&AN=96324982&site=eds-live&scope=site