Analysis
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NR603-MENTALHEALTH.docxfrom Week 6: Mental Health Clinical Presentation - Part 1
Apr 7, 2021 9:55PM
Mental illness goes undiagnosed in so many individuals living in the United States. Studies have shown it to affect approximately one in every five (19 percent) of adults. The American Psychiatric Association (APA) (2019) defines mental illnesses as health conditions affecting deviations in emotion, thinking or behavior (or a combination of these). These illnesses are also coupled with distress and/or difficulties acting in social, work or family events.
Case study:
George is a 27-year-old, single, Caucasian male who came to the clinic seeking medication for his fatigue, lack of energy, reduced sex drive and withdrawn behavior. Which he states this feeling happens to him all the time, around this time of year(winter) for the past 2 years.
Patient Information:
G.A. 27-year-old Caucasian male
CC (chief complaint): fatigue, lack of energy, reduced sex drive, and withdrawn behavior
HPI: G.A. is a 27-year-old, single, Caucasian male who came to the clinic seeking medication that will help with his fatigue, lack of energy, reduced sex drive, and withdrawn behavior. He stated that his symptoms had been harsh this year around wintertime and is now wanting to seek help because it has affected his personal life. He reported that he started feeling this way 2 years ago, and is becoming more withdrawn from the things that he normally enjoys doing. He denied seeking help because he was afraid of being labeled.
Current Medications: None.
Allergies: NKDA.
PMHx: Immunizations are current. Reports having no medical problems.
PSHx: None
Social Hx: Single Caucasian male. G.A. is an only child. He lives with his divorced mother. He denies drinking, smoking and illegal drug use.
Fam Hx: Father was an alcoholic and is now deceased from a motor vehicle accident 5 years ago. Mother 65 is alive and suffers from depression. No other pertinent family hx reported.
ROS:
Constitutional: States he lost 10lbs in the last month. Negative for chills, fever, weakness, and night sweats
HEENT: Eyes: No visual loss, PERRLA. Ears, Nose, Throat: No hearing loss, nasal congestion, or sore throat.
Skin: Normal temperature, tone, texture, turgor and no rash or itching.
Cardiovascular: No chest pain, discomfort, and palpitations. No edema.
Respiratory: No shortness of breath. No cough or sputum.
Gastrointestinal: No nausea, vomiting, diarrhea, or abdominal pain. Abdomen soft, non-tender, non-distended, bowel sounds active in all four quadrants.
Genitourinary: No sign of dysuria or polyuria and voiding freely
Neurological: No headache, dizziness, or syncope and numbness or tingling.
Musculoskeletal: No back pain, muscle, and joint pain or stiffness.
Hematologic: Negative for bleeding or bruising.
Lymphatics: Negative for enlarged nodes.
Psychiatric: Family hx of depression (mother)
Endocrinologic: No polyuria or polydipsia.
Allergies: NKDA.
Physical exam:
Vital signs: BP 110/60, Pulse 100, Temp 36.1 C, Resp 20, Height 6' 1", Weight 170lb.
General: Flat affect, no eye contact, patient looks at floor while speaking. Speaks in a low tone
HEENT: Head normocephalic and atraumatic. Hair evenly distributed throughout the scalp. Eyes: Sclera clear. Conjunctiva: white, PERRLA, EOMs intact bilateral. Ears: Tympanic membranes gray and intact and no discharge or erythema. Nose: Nares normal, septum midline, mucosal pink and moist and no drainage or sinus tenderness. Throat: Lips, mucosa and tongue normal, no lesions or exudate. Neck. Supple, trachea midline, no tenderness, no cervical lymphadenopathy or nodules. No carotid bruit or JVD. Thyroid midline: small and firm without palpable masses.
Lungs: Lungs clear to auscultation bilaterally. Respirations even and unlabored.
Cardiovascular: S1 and S2 normal, no murmur, rub or gallop. RRR, no displaced PMI. Peripheral pulses equal bilaterally, no peripheral edema.
Abdomen: Soft, non-tender, non-distended, bowel sounds present in all four quadrants. No hernias and no masses. No organomegaly.
Genitalia: Deferred.
Rectal: Deferred.
Musculoskeletal: Moves all extremities, good ROM, no edema
Skin: Warm to touch, normal tone, texture, turgor, no induration, no rash and no lesions.
Neurologic: Negative for any deficits
Psychiatric: Flat affect.
Reference:
American Psychiatric Association. (2019). What is mental illness?Retrieved from https://www. psychiatry.org/patients-families/what-is-mental-illness
from Week 6: Mental Health Clinical Presentation - Part 1
Apr 9, 2021 3:57PM
Thank you for sharing Taylor, great case study to analyze and learn from. After reading your case study, I picked the following differential diagnosis:
1. Postpartum Depression F53.0
The Diagnostic and Statistical Manual of Mental Disorders defines postpartum depression as a major depression that begins around 4 weeks after delivery. However, many studies indicate that a woman is vulnerable for up to 12 months postpartum. Postpartum depression is a form of severe depression after delivery that interferes with daily functioning and requires treatment. A woman with postpartum depression may experience feelings of sadness, despair, anxiety, and irritability to a severe degree. According to Hollier (2018) SSRI, SNRIs, atypical antidepressants, tricyclic antidepressants would be the treatment of choice, but SSRIs are considered safe and would not be fatal if patient overuses this medication.
2. Anxiety disorders F41.9
Generalized anxiety disorder (GAD) is characterized by excessive and persistent worrying that is hard to control, causes significant distress or impairment, and occurs on more days than not for at least six months. The hallmark symptoms of anxiety will include apprehensiveness and irritability, increased fatigue and muscular tension (Oji & Heering, 2018). An effective treatment for generalized anxiety disorder includes psychological interventions such as cognitive-behavioral therapy, relaxation techniques, and medications including selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors.
3. Major depression disorder F41.0
Depression is a mental health disorder that affect cognitive, emotional and behavioral aspect of life in patients that suffer from it. The major symptoms are depressed mood and the inability of enjoying activities that were enjoyable before (Hollier, 2018). The most common causes of depression are recent tragedy, financial problems, stress from work, etc. The PHQ-9 will be a helpful tool to assess major depression disorder and is listed in the DSM-5 exclusively focuses on the nine diagnostic criteria for major depression listed in the DSM-5 (chung, et al., 2016). According to Hollier (2018) SSRI, SNRIs, atypical antidepressants, tricyclic antidepressants would be the treatment of choice, but SSRIs are considered safe and would not be fatal if patient overuses this medication. Medication and psychotherapy are effective for most people who are diagnosed with depression.
The primary diagnosis I would select for this patient based on your case study is postpartum depression. For this patient I would recommend joining a support group, engage is some self-care relaxation techniques such as exercising, warm-baths, and massages. If symptoms become worse, I would start her on the first-line medication for the treatment of depression which is selective serotonin reuptake inhibitors (SSRIs), Lexapro 10 mg 1 tablet by mouth daily in combination with cognitive behavioral therapy and psychotherapy or psychiatric counseling.
References:
American College of Obstetricians and Gynecologists. Depression and Postpartum Depression: Resource Overview. Retrieved from: https://www.acog.org/Womens-Health/Depression-and-Postpartum-Depression
Chung M., Choon, H., Yin, P., & Chung W. (2016). Major depression in primary care: making the diagnosis. Singapore medical journal, 57(11), 591–597. doi:10.11622/smedj.2016174
Hollier, A. (2018). Clinical Guidelines in Primary Care (3rd ed.). Lafayette, LA. Advanced Practice Education Associates, INC.
Oji, O. D. A. F.-B., & Heering, H. R. C. (2018). Generalized Anxiety Disorder. CINAHL Nursing Guide. Retrieved from https://search-ebscohost-com.chamberlainuniversity.idm.oclc.org/login.aspx?direct=true&db=nup&AN=T701457&site=eds-live&scope=site
from Week 6: Mental Health Clinical Presentation - Part 1
Apr 12, 2021 10:16AM
Thank you professor, I would refer to a Psychiatrist and Psychologist.
from Week 6: Mental Health Clinical Presentation - Part 1
Apr 12, 2021 10:51AM
Lindsey you are correct, the primary diagnosis is seasonal affective disorder (SAD). It is good to know that seasonal affective disorder (SAD) is a depression type that involves the occurrence of depression signs at a particular time each year. It usually occurs during the winter seasons when there is reduced sunlight (Nussbaumer‐Streit, Forneris, Morgan, Van Noord (Gaynes, Greenblatt, & Gartlehner, 2019). A decrease in sunlight causes the disease. I would treat this patient with psychotherapies like cognitive processing therapy (CBT), light therapy along with SSRI antidepressants medications like Bupropion XL, the only approved SAD's medication FDA, for controlling serotonin levels in the brain to reduce SAD symptoms (Nussbaumer-Streit, Thaler, Chapman, Probst, Winkler, Sönnichsen, & Gartlehner, 2021)
Reference
Nussbaumer‐Streit, B., Forneris, C. A., Morgan, L. C., Van Noord, M. G., Gaynes, B. N., Greenblatt, A., ... & Gartlehner, G. (2019). Light therapy for preventing seasonal affective disorder. Cochrane Database of Systematic Reviews, (3).
Seasonal Affective Disorder Treatment Plan
Patient Information:
G.A. 27-year-old Caucasian male
CC (chief complaint): fatigue, lack of energy, reduced sex drive, and withdrawn behavior
HPI: G.A. is a 27-year-old, single, Caucasian male who came to the clinic seeking medication that will help with his fatigue, lack of energy, reduced sex drive, and withdrawn behavior. He stated that his symptoms had been harsh this year around wintertime and is now wanting to seek help because it has affected his personal life. He reported that he started feeling this way 2 years ago and is becoming more withdrawn from the things that he normally enjoys doing. He denied seeking help because he was afraid of being labeled.
A:
Diagnosis: Seasonal affective disorder, also known as SAD (R53. 83)
It is good to know that seasonal affective disorder (SAD) is a depression type that involves the occurrence of depression signs at a particular time each year. It usually occurs during the winter seasons when there is reduced sunlight (Nussbaumer‐Streit, Forneris, Morgan, Van Noord (Gaynes, Greenblatt, & Gartlehner, 2019). A decrease in sunlight causes the disease. SAD patients need a comprehensive management plan grounded on clinical judgment, patient preference, practice guidelines, and possible patient response to treatment, which are critical factors for treating SAD.
Clinical practice guidelines applicable to G.A involve psychotherapies like cognitive processing therapy (CBT), light therapy along with SSRI antidepressants medications like Bupropion XL, the only approved SAD's medication FDA, for controlling serotonin levels in the brain to reduce SAD symptoms (Nussbaumer-Streit, Thaler, Chapman, Probst, Winkler, Sönnichsen, & Gartlehner, 2021)
Lessons learned from the discussion are the need for thorough examination of the patient's condition, including paying attention to details, asking the right questions, and listening carefully and patiently to make the right care decision and referrals.
Final Treatment Plan/Analysis:
ANALYSIS
There is sufficient evidence that the brain generates the hormone melatonin to assist in sleeping when it is darker. Sunlight triggers the brain to stop the production of the hormone, therefore making a person more alert and awake. During winter, when there are short days and longer nights, the human body generates a lot of melatonin hormone, leaving one feeling low of energy and drowsy (Pjrek, Friedrich, Cambioli, Dold, Jäger, Komorowski, & Winkler, 2020). Again, reduced sunlight decreases the production of serotonin, which is a neurotransmitter for regulating mood; this creates the need for light therapy.
Medication prescribed:
Bupropion Hydrochloride 150mg
Form of dosage: Tablet, extended release
150 mg every morning for seven days, and then the dosage can be increased to 300 mg daily in the morning.
Swallow the whole tablet without crushing, chewing, or dividing.
Follow-up:
A psychologist or psychiatrist should reassess the medication's effect within two to four weeks after the start of administration.
Coding and Billing:
ICD-10 code is R53. 83- Seasonal Affective Disorder (SAD)
References
Nussbaumer‐Streit, B., Forneris, C. A., Morgan, L. C., Van Noord, M. G., Gaynes, B. N., Greenblatt, A., ... & Gartlehner, G. (2019). Light therapy for preventing seasonal affective disorder. Cochrane Database of Systematic Reviews, (3).
Nussbaumer-Streit, B., Thaler, K., Chapman, A., Probst, T., Winkler, D., Sönnichsen, A., ... & Gartlehner, G. (2021). Second‐generation antidepressants for treatment of seasonal affective disorder. Cochrane Database of Systematic Reviews, (3).
Pjrek, E., Friedrich, M. E., Cambioli, L., Dold, M., Jäger, F., Komorowski, A., ... & Winkler, D. (2020). The efficacy of light therapy in the treatment of seasonal affective disorder: a meta-analysis of randomized controlled trials. Psychotherapy and psychosomatics, 89(1), 17-24.
