SUNSG6440PC is a 32-year-old Hispanic female who presented to clinic with complaint of feeling sad, down, difficulty concentrating when reading a book

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 SUNSG6440PC is a 32-year-old Hispanic female who presented to clinic with complaint of feeling sad, down, difficulty concentrating when reading a book. Onset 4 weeks ago when she found her husband cheating on her. Patient endorses she enjoy attending to church every Sunday and this is no longer pleasant for her. She get tired easily with fatigue and mental fogginess. Patient verbalized her also wakes up every day around 4-5 am and has difficulty falling sleep again. Patient described that very often she feels with palpitations ad anxious. Denies prior episode, denies accident or trauma.

Medications: Denes taking any current medication

PMH: Denies any prior medical or surgical history

Allergies: NKDA

Medication Intolerances: No known medication or food allergies. 

Chronic Illnesses/Major traumas. None

Hospitalizations/Surgeries. Denies any previous hospitalization or surgeries

Family History

Parents are alive, father is healthy. Mother has been diagnosed with major Depressive disorder. Patient has two brothers healthy and alive.

 

Social History

The patient is an accountant.  Patient is married and lives with her husband and a 3 years old daughter. Denies alcohol/drug use/abuse .Denies smoking. Feel safe at home.

ROS

General

Positive for fatigue, lack of interest on things that were enjoyable for her fatigue, positive for tiredness and lack of appetite. Denies fever, night sweats.     Cardiovascular

Positive for  palpitations, Denies Chest pain PND, orthopnea, edema

 

Skin

Denies rashes, bruising, bleeding or skin discolorations, any changes in lesions or moles Respiratory

Denies wheeze, dyspnea, cough nor night sweats.

Eyes

Denies wearing Corrective lenses, blurring, and visual changes of any kind.

                Gastrointestinal

Denies nausea, vomiting nor diarrhea, changes in appetite, pain nor difficulty in swallowing. He also denies heartburn, constipation nor changes in bowel habits.

Ears

Denies Ear pain, hearing loss, ringing in ears, discharge

.               Genitourinary/Gynecological

She is para 1+0. Menarche was at 14 years with a cycle of 28 days regular Denies excessive bleeding Denies contraceptive use at this time. Last pap smear done on 2021 and was negative along with mammogram.Denies vaginal discharge, changes in urine color, dysuria nor hematuria.

Nose/Mouth/Throat

Denies Sinus problems, dysphagia, nose bleeds, dental disease, hoarseness, throat pain

                Musculoskeletal

Denies Back pain, joint swelling, stiffness or pain, fracture hx.

Breast

Denies breast lump, nor any significant breast changes.                 Neurological

Denies headache, syncope, seizures, transient paralysis, weakness, and paresthesia.

Heme/Lymph/Endo 

Denies HIV  ,bruising, blood transfusion hx, swollen glands, increase thirst, increase hunger, cold or heat intolerance                Psychiatric

Positive for depression, sadness, anxiety, anhedonia, lack of concentration, feeling overwhelm, fatigue sleeping difficulties, Denies suicidal ideation/attempts, previous dx.

OBJECTIVE

Weight   150 lbs                 Temp 97.9F         BP 120/66 mmhg

Height 5.6            Pulse 87beats/minute   Resp 20 breaths/minute

General Appearance

The patient is a female sad appearing, Crying and cooperative well groomed. AAOx4

Skin

Skin is warm, dry, clean and intact. No rashes or lesions noted.

HEENT

Head is normocephalic, atraumatic and without lesions; hair evenly distributed. Eyes:  PERRLA. EOMs intact. No conjunctival or scleral injection. Ears: Canals patent. Bilateral TMs pearly gray with positive light reflex; landmarks easily visualized. Nose: Nasal mucosa pink; normal turbinates. No septal deviation. Neck: Supple. Full ROM; no cervical lymphadenopathy. No thyromegaly or nodules. Oral mucosa pink and moist. Pharynx erythematous and without exudate. Teeth are in good repair.

Cardiovascular

S1, S2 with regular rate and rhythm.  No extra sounds, clicks, rubs or murmurs. Capillary refill 2 seconds. Pulses 3+ throughout. No edema.

Respiratory

The chest moves with respiration, no scars, symmetrical with normal bilateral expansion. Bilateral air entry, not bronchial sounds, no rhonchi.

Gastrointestinal

Abdomen is non-distended and soft, moves with respiration, and has no scars with no lesions. BS in all 4 quadrants are normoactive

Breast

No changes in breast color, no breast lumps, no nipple discharges nor breast pain.

Genitourinary

Patient refused

Musculoskeletal

Full ROM seen in all 4 extremities as patient moved about the exam room.

Neurological

. Good tone. Posture erect. Balance stable; gait normal.

Psychiatric

Alert and oriented. Patient is depressed with flattened affect slow speech and movement, long pauses, tearfulness, poor concentration with change on sleeping patterns, early awakenings, anhedonia, and anxiety. Denies SI/HI. Express hopelessness

Lab Tests

Complete blood count- pending results

Thyroid Function studies - pending results

Urine Toxicology –Pending results

Complete Metabolic Panel –Pending Results

 

Rationale: Utility of screening laboratory test has not been demonstrated .Nevertheless, in patients with new onset depression some test may be helpful. (Lyness, 2022).

 

Special Tests

None

 Diagnosis

Differential Diagnosis

1-            Bipolar Disorder   F31.9

Pertinent positive: Signs and symptoms of depression.

Pertinent negative: Absence of maniac or hypomania episodes.

Rationale: Bipolar disorder frequently disrupts mood, energy m activity, sleep, cognition and behavior. It is a mood disorder characterized by episodes of mania, hypomania and MDD. Thus patient lack of episodes of mania or hypomania (Suppes,2022).

 

2-            Hypotyroidism E03.9

Pertinent Positive:  Lack of energy , fatigue, slow speech and movement

Pertinent Negative : Depressed mood  for more than 4 weeks following an stressor, lack of constipation , weight gain , cold intolerance, absence of bradycardia

Rationale : Hypothyroidism results from hypothalamic –pituitary disease or primary thyroid disease . Affect most all organ systems. Signs and symptoms are related to a generalized slowing of metabolic processes and can lead to fatigue, slow movement and speech, cold intolerance, constipation , weight gain, delayed relaxation of deep tendon reflexes and bradycardia. (Surks, 2022).

3-Chronic Fatigue Syndrome (CFS) R53.82

Pertinent Positives : Tiredness, Low energy level , fatigue .

Pertinent negative:  Patient is endorsing signs and symptoms of depressed mood

Rationale: This general syndrome can be caused for multiple medical conditions affecting any organ system. Initial and physical assessment with a comprehensive lab work up will be very helpful identifying the cause. (Fosnocht , 2022)

.

3-            Final Diagnosis: Major Depressive Disorder (MDD ) , Single episode  F32.9

Pertinent positive:   History of stressor (husband cheating) .4 weeks history of anhedonia, depression, anxiety, lack of energy, poor concentration, changes on sleep patterns. Feeling overwhelmed. Family history of first-degree family diagnosed with MDD. During screening questions and use of standard screening tool, SIG E CAPS patient has at least five of these symptoms present for at least 2 weeks. (Rhoads ,2021 9. 117-133).

Rationale: MDD is a constellation of symptoms and signs that include depressed mood, loss of interest or pleasure in most or all activities, Insomnia or hypersomnia , Psychomotor retardation, fatigue or low energy , decrease ability to concentrate : that persist most days for more than 2 weeks.  (Lyness,2022).

 

 

Plan/Therapeutics

Further testing: No further testing require

Medications: SSRIs (Selective Serotonin Reuptake Inhibitors) such as .Sertraline (Zoloft) 50 mg orally every morning.

Rationale: Psychotropic medication should be selected on relative efficacy, tolerability, and anticipated side effects. SSRIs are one of the most commonly medication used to treat MDD. SSRIs typically display fewer side effects that other antidepressants. (Rhoads, 2021).

Education: Educate patient that it might take 2 to 4 weeks prior to beneficial effects and 4 to 8 weeks prior to full effect of the dosage.

Non-medication: Educate patient on proper sleep-hygiene, decrease use or elimination of caffeine, tobacco and alcohol. Cognitive restructuring involves substituting positive perceptions for negative perceptions and assistance with problem solving and stress management.

Follow-up: Patient will be followed up in 2 weeks after initiation of therapy for evaluation of adverse drug effect. I would pay careful attention to the first 4 weeks of treatment to a sudden lift of depression or to worsening mood as initial response to antidepressant therapy, as these could be signs of increase risk of suicide. Patient will be followed up on monthly basis and referred to a psychiatric if needed.