CASE STUDY-Seasonal Affective Disorder

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single, Caucasian male who came to the clinic seeking medication for his fatigue, lack of energy, reduced sex drive and withdrawn behavior.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CC (chief complaint): fatigue, lack of energy, reduced sex drive, and withdrawn behavior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male who came to the clinic seeking medication that will help with his fatigue, lack of energy, reduced sex drive, and withdrawn behavior.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 He reported that he started feeling this way 2 years ago, and is becoming more withdrawn from the things that he normally enjoys doing.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