Week (enter week #): (Enter assignment title) Student\'s Name Institutional Affiliation, Professor Course Date
Subjective: CC (chief complaint): Initial psychiatric evaluation
HPI: ZH is a 26-year-old white male presenting for an initial psychiatric evaluation. The Phq9 is 19, Gad is 17, while the Mdq is positive. However, he denies hallucinations, delusions, and suicidal or homicidal ideation. He is alert and oriented to place, time, and person. The patient reports that he is looking for a new mental health provider since he has struggled with anxiety and depression his entire adult life. He reports that previously, he has been diagnosed with GAD, MDD, and panic disorder. The patient reports that during the summer, he was hopeless and had suicidal ideations for about two months. He reports having depressive symptoms, which can last for several months, and he loses temper easily. He reports frequent rumination on childhood abuse that results in him zoning out. He reports a feeling of helplessness and hopelessness. He has tried taking several antidepressants for his condition but in vain, although he reports that Rumeron worked for him but had adverse effects like weight gain. He reports that, at times, he feels paranoid, which results in him isolating himself from others. He reports having panic attacks approximately once per week and rates his current anxiety as 6/10. The patient reports that he attends therapy twice monthly. The patient reports that he compulsively checks to ensure that all doors are closed, and the stove is turned off. He reports difficulty falling asleep as a result of persistent pain.
Substance Current Use: The patient denies tobacco smoking, alcohol intake, and caffeine use. He also denies abuse or use of any illegal substances.
Past Medical History: The patient reports a history of chronic pain, degenerative joint disease, constipation, insomnia, and depression. The patient reports a past surgical history of 3 level fusion for multilevel degenerative disc disease. The patient reports that he has had three psychiatric hospitalizations. In 2014, the patient was admitted for 4 days due to suicidal attempts and was managed. In 2018 the patient was admitted for 10 days due to suicidal ideations and was managed. He reported an admission in 2019 for 6 days due to suicidal ideations and was managed. The patient also reports a history of emotional and physical trauma. He reports that he attends therapy for his psychiatric condition twice.
- Current Medications: The patient is currently on doxepin 25 mg per oral at bedtime, doxepin 50 mg per oral at bedtime, lyrica 100 mg per oral four times daily, and oxycodone 5 mg per oral four times daily. The patient is currently not in any herbal drugs, homeopathic products, or over-the-counter medications.
- Allergies: The patient has no known food, environmental, or drug allergies
- Reproductive Hx: Noncontributory
Family History: The patient is from a family of four children; 1 half-sibling and 2 full siblings. Both the father and mother are alive. The father has hypertension and diabetes mellitus. The mother has hypertension that is controlled. The patient reports that the uncle has a schizoaffective disorder that is being managed.
Socio-economic History: The patient has studied up to college level. His current income is SSI/SSDI. The patient lives with his parents and siblings.
ROS:
- GENERAL: The patient denies fatigue, weakness, fever, chills, or weight loss.
- HEENT: The patient denies visual disturbance, schotomous vision, blurred vision, yellow sclera, or double vision. The patient denies sore throat, anosmia, voice hoarseness, hearing problems, running nose, nasal congestion, sneezing, mouth deviation, or abnormal mouth movements.
- SKIN: The patient denies pruritus, skin itchiness, or skin rashes.
- CARDIOVASCULAR: The patient denies palpitations, easy fatiguability, peripheral edema, chest pressure, chest discomfort, or chest pain.
- RESPIRATORY: The patient denies breathing difficulties, shortness of breath, chest pain, cough
- GASTROINTESTINAL: The patient denies nausea, vomiting, diarrhea, anorexia, abdominal pain, constipation, or appetite loss.
- PERIPHERAL VASCULAR: The patient denies varicose veins, phlebitis, or lower extremity edema.
- GENITOURINARY: The patient denies nocturia, urinary urgency, hesitancy, painful micturition, urinary frequency, blood in urine, urinary retention, urethral discharge, or straining.
- NEUROLOGICAL: The patient denies dizziness, headache, confusion, numbness, paralysis, tingling sensation, ataxia, or syncope. He denies alterations in bladder and bowel control.
- MUSCULOSKELETAL: The patient denies muscle ache, joint stiffness or pain, muscle weakness, or back pain.
- HEMATOLOGIC: The patient denies anemia, easy bruising, or bleeding problems.
- LYMPHATICS: No lymphadenopathy, lymphadenitis, or history of splenectomy
- ENDOCRINOLOGIC: The patient reports average sweating. He denies having thyroid problems, polydipsia, polyuria, heat intolerance, or cold intolerance. He denies hyperactivity or restlessness.
- PSYCHIATRIC: The patient reports racing thoughts, feeling of worthlessness, easy irritability, anxiety, insomnia, mental disturbance, anxiety attack, depression, anger, mood swings, helplessness, hopelessness, paranoia, flashbacks, suicidal ideation, change in appetite, and avoidance.
Objective Physical examination:
Vital Signs: BP 120/80; Pulse 72 b/min; spo2 97%; RR 17 breaths/min; Temp 35.8 degrees celcius; Wt 65kg; Ht 67
General: The patient is sitting upright in a chair, slightly leaning forward, in a general fair condition, not in obvious pain, not in respiratory distress. No chronic ill appearance. The patient is well nourished and well hydrated. The patient has a scar on the right forearm. No palmar pallor/jaundice, no peripheral cyanosis, the capillary refill is less than 2 seconds, no splinter hemorrhages, no Janeway lesions, no Osler\'s nodes, no finger clubbing, no koilonychia, no leukonychia, the radial pulse is present, symmetrical, regular, of good volume. The pulse rate is 72bpm. Brachial pulse is present. No lymphadenopathy, normal hair head distribution, no scleral jaundice, no conjunctival pallor, lips are well hydrated, no angular stomatitis, good oral hygiene, no atrophic glossitis, no central cyanosis, no pedal/tibial edema.
Systemic: HEENT: nomocephalic atraumatic, able to see properly, able to hear properly, no neck stiffness, no running nose, normal voice tone, no neck swelling, no mouth deviation, no abnormal mouth movement
SKIN: warm to touch, no rashes, no pruritus, no hives, no moles or skin lesions
RESPIRATORY: No shortness of breath, no chest tenderness, no shortness of breath. On palpation, no cough or sputum. Lungs are clear on auscultation. Inspection The chest is bilaterally symmetrical, there is bilateral symmetrical chest expansion, and it has an elliptical cross-section. The chest moves with respirations, and the movements are symmetrical. There are no visible scars or therapeutic marks. There are no visible masses. The respiratory rate is 17 bpm. The respiratory rhythm is constant and regular. Palpation No cervical, supraclavicular or axillary lymphadenopathy, No chest tenderness or swelling, No palpable abnormal masses, the trachea is located centrally, bilaterally symmetrical chest expansion. Tactile fremitus is normal and equal bilaterally Resonant percussion tone On auscultation, there is bilateral air entry, and vesicular breath sounds are appreciated.
CARDIOVASCULAR: On inspection, there are no scars or therapeutic marks, and the precordium is normative On palpation, the apex beat is located at the 5th intercostal space near the midclavicular line On auscultation, both S1 and S2 were appreciated. No murmurs or added sounds
ABDOMINAL EXAMINATION On inspection, the abdomen is symmetrical, no visible masses. The abdomen is slightly scaphoid and moves with respiration. There are no visible scars or therapeutic marks. The umbilicus is inverted On superficial palpation, the abdominal skin is warm to touch. There is no tenderness or palpable mass in the abdomen On deep palpation, there is no abdominal tenderness, palpable masses, or enlarged organs On percussion, the tone is tympanic, no shifting dullness, the fluid thrill is negative On auscultation, the bowel sounds are present. No vascular bruits
CENTRAL NERVOUS SYSTEM GCS score is 15/15 Normal muscle tone, bulk, and power
NEUROLOGICAL No paralysis, ataxia, numbness, headache, or difficulties emptying bowel or bladder. History of insomnia.
PSYCHIATRIC Normal cooperation, cooperative speech, normal speech volume
MUSCULOSKELETAL Normal gait, normal muscle strength, no muscle ache, no joint stiffness, no joint pain
Diagnostic results:
Full Hemogram To rule out anemia as a cause of MDD and anxiety.
Serology To rule out neurosyphilis and HIV as a cause of depression
Electrolytes To help identify electrolytes levels since low sodium levels can induce depression.
Biomarkers Specific biomarkers are present in individuals with certain mental illnesses, which can confirm a diagnosis of MDD.
Proteins Low plasma protein levels found in depressed individuals might indicate a lack of feeding. High protein levels increase the bioavailability of specific drugs due to reduced binding proteins.
Alcohol and substance screening Drug and alcohol abuse can result in depressive symptoms.
Thyroid function tests To rule out any thyroid problem since hyperthyroidism can result in depression or anxiety
Electrocardiography To identify conduction issues in the heart resulting from medications such as antidepressants
Electroencephalography Rule out a brain tumor and seizure disorder
Assessment: Mental Status Examination: GE is a 26-year-old male patient of Caucasian descent who looks his mentioned age. He is dressed properly for the occasion. The patient is well nourished, well hydrated, and not distressed. The patient is alert, cooperative, attentive, and has good concentration. He could say the days of the week and months backward correctly. He maintains eye contact with the interviewer. His speech is coherent, clear, and normal in terms of tone, rhythm, and volume. He does not exhibit any psychomotor abnormalities, such as tremors. He is oriented to time, place, person, day, and date. His mood is euthymic, neither manic nor depressive. He denies any past or current suicidal thoughts, homicidal ideation, or self-harming behaviors. However, the patient reports a feeling of worthlessness, hopelessness, helplessness, and racing thoughts. He has no illusions, sdepersonalization, delusions, or hallucinations. He has good abstraction and lacks insight, and has poor judgment. His recent memory, remote memory, registration, and short-term memory are intact. His intelligence is good since he can tell the similarity and differences between a fence and a wall. Diagnostic Impression:
Major Depressive Disorder (MDD), recurrent, moderate (F331) Major depressive disorder, recurrent, moderate, is a psychiatric illness characterized by persistent and pervasive low mood accompanied by loss of pleasure and interest in usually enjoyable events and low self-esteem. DSM-5 diagnostic criterion for MDD include; feelings of hopelessness, sadness, tearfulness or emptiness, frustrations, irritability or angry outbursts, loss of pleasure or interest in normal activities including hobbies, lack of energy and tiredness, restlessness, agitation or anxiety, slowed body movements, speaking or thinking, feeling of guilt or worthlessness, suicidal thoughts or ideations, difficulties thinking, making decisions, remembering things and concentrating, sleep disturbance, including hypersomnia and insomnia and unexplained physical issues including headaches or back pain (Belmaker & Agam, 2018). The patient is suspected of having major depressive disorder because he reports feelings of helplessness, hopelessness, worthlessness, irritability, anger, insomnia, avoidance, mental disturbance, and suicidal ideation. He also reports having three psychiatric admissions, one due to suicidal attempts and two due to suicidal ideations. The exact cause of MDD is unknown, but many factors are involved. They include biological differences, hormones, inherited traits, and brain chemistry. Factors that increase the risk of an individual developing the condition include alcohol and drug abuse, chronic illnesses such as cancer, other mental disorders, family history of MDD, certain medications, stressful or traumatic life events, and certain personality traits. The condition is treatable and manageable using medications and psychotherapy (Otte et al., 2016). Forms of psychotherapy that can be used include cognitive behavioral therapy, psychodynamic therapy, and interpersonal therapy. Differential Diagnosis;
Generalized Anxiety Disorder (GAD) GAD is excessive and prolonged anxiety that is not focused on a specific fear but involves multiple things such as work and health. Clinically, the disorder causes significant distress. However, it is not caused by underlying medical diseases, medications, or substance abuse. Affected individuals usually present with restlessness, nervousness, irritability, muscle tension, fatigue, somnolence, concentration difficulties, and insomnia (Fricchione, 2014). The patient is suspected of having GAD because he reports having insomnia, anxiety, anxiety attack, and irritability. GAD can be treated using both pharmacotherapy and psychotherapy. The first-line drug used Selective Serotonin Reuptake Inhibitors (SSRI), while the second-line included SNRI, TCA, buspirone, and benzodiazepine. Psychotherapy entails biofeedback, applied relaxation therapy, and CBT.
Insomnia due to other mental disorders (F5105) Insomnia disorder is a dissatisfying sleep quality and quantity that causes daytime dysfunction. The etiology of insomnia disorder is complex and not wholly understood. However, its predisposing factors include chronic physiological hyperarousal and cognitive state and comorbidities such as anxiety and mood disorders. Precipitating factors acutely trigger the condition, including stressful or traumatic life events. Poor sleep hygiene perpetuates the condition. Insomnia can often coexist with other mental diseases, increasing the psychiatric relapse risk and the medical burden. Insomnia can also be linked to neurological and medical conditions. Some drugs might also induce sleeplessness (Hertenstein et al., 2019). Insomnia treatment and management can have a favorable impact by reducing symptoms and controlling these coexisting diseases, and avoiding future occurrences. Insomnia can be caused by mental disorders such as depression, anxiety disorders, attention deficit hyperactivity disorder, and psychotic disorders. This patient is suspected of having insomnia because he reports episodes of insomnia. Other mental disorders likely cause insomnia because he presents with many symptoms suggesting a coexisting mental disorder. The symptoms include a feeling of worthlessness, hopelessness, anger, mood swings, suicidal ideations, suicidal attempt, and paranoia.
Agoraphobia with panic disorder (F4001) Agoraphobia with panic disorder is a phobic-anxious condition where victims avoid places or situations where they fear being unable to flee or seek help or being embarrassed if they experience a panic attack. For many years, agoraphobia has been regarded as inextricably tied to the periodic panic attack syndrome, to the point that it appears to be the complication or typical development of panic disorder in most instances. Despite the significant agoraphobia with panic disorder prevalence in primary care patients, medical professionals frequently fail to recognize and treat the disease (Goisman et al., 2017). Antidepressants help prevent panic episodes and improve avoidance behavior and anticipatory anxiety. These medications are also beneficial in treating the commonly accompanying depressive symptoms. The patient is suspected of having this disorder because he reports having anxiety, anxiety attacks, and avoidance behavior. Reflections: The patient has Major Depressive Disorder, recurrent, moderate, which is expected to improve due to pharmacotherapy. The patient is currently on doxepin 25mg po hs, doxepin 50mg po, lyrica 100mg po qid and oxycodone 5mg po qid. Doxepin is an antidepressant in the TCA class, and it works by increasing the concentration of norepinephrine and serotonin neurotransmitters, improving message transmission between neurons. The mentioned drugs improve the symptoms experienced by the patient. The patient needs insight-oriented and psychotic psychotherapy for treatment to be effective. This is because the patient lacks insight and has a poor judgment about his condition. In insight-oriented therapy, the therapist collaborates with the victim to create a narrative that makes sense of the patient\'s past and the situation to aid comprehension and provide perspective. Having a good insight into the condition helps the patient recover faster. I would therefore start the patient on psychotherapy will also help the patient change his view about himself and events. Forms of psychotherapy that can be used include CBT, interpersonal therapy, psychodynamic therapy, humanistic and integrative therapy.
Treatment Plan: The goal of treatment is to prevent psychiatric admission, anxiety, anxiety attack, racing thoughts, feeling of worthlessness and hopelessness, suicidal ideations, and suicidal attempts. It will also instill insight and judgment in the patient. The care plan will seek to manage Major Depressive Disorder by improving symptoms. Treatment for the patient should entail both pharmacological and non-pharmacological treatment modalities. Pharmacological treatment entails doxepin 50 mg per oral at bedtime. Doxepin is a TCA antidepressant that reduces symptoms of MDD such as insomnia and relieves anxiety, mood swings, and anger by improving communication between neurons. The patient is encouraged to adhere to the medication prescription and should not stop taking the medication without consulting his doctor. He is also advised not to take the drug within three hours after eating since drug-food interactions reduce efficacy. The patient is advised to beware and report any adverse effects such as blurred vision and dizziness. Other antidepressant drug classes that can be used include SSRIs (Fluoxetine), SNRIs (Venlafaxine), Tetracyclic antidepressants (Remeron), MAOIs (phenelzine), NMDA receptor antagonists (esketamine), and bupropion The patient should be given psychotherapy, and in this case, CBT is the best form. CBT will focus on reducing unhelpful or negative .behaviors and thoughts such as a feeling of hopelessness and worthlessness, and self- solation. The patient should attend 12 to 20 sessions but experience improvements after a few sessions. Other forms of psychotherapy include psychodynamic therapy, interpersonal therapy, and humanity therapy Safety plan discussed with the patient: Inform a friend; call the office; call crisis line 1-800-715-4225; report to the ER or call 911 if you develop suicidal thoughts or ideations or MDD symptoms. Follow up in 1-month PGx for side effect management, meaningful drug efficacy predictors, and medication refill. Continue psychotherapythe patient will fill the PHQ-98 scale and return at the next visit.
References Belmaker, R. H., & Agam, G. (2018). Major depressive disorder. New England Journal of Medicine, 358(1), 55-68. Fricchione, G. (2014). Generalized anxiety disorder. New England Journal of Medicine, 351(7), 675-682. Goisman, R. M., Warshaw, M. G., Peterson, L. G., Rogers, M. P., Cuneo, P., Hunt, M. F., ... & Keller, M. B. (2017). Panic, agoraphobia, and panic disorder with agoraphobia: data from a multicenter anxiety disorders study. Journal of Nervous and mental Disease. Hertenstein, E., Feige, B., Gmeiner, T., Kienzler, C., Spiegelhalder, K., Johann, A., ... & Baglioni, C. (2019). Insomnia as a predictor of mental disorders: a systematic review and meta-analysis. Sleep medicine reviews, 43, 96-105. Otte, C., Gold, S. M., Penninx, B. W., Pariante, C. M., Etkin, A., Fava, M., ... & Schatzberg, A. F. (2016). Major depressive disorder. Nature reviews Disease primers, 2(1), 1-20.
