post response

Subjective:

CC (chief complaint): The patient is here as a referral from his primary care provider at VA. He is here for psychiatric evaluation and continuity of his medication.

HPI: Patient is 31 years-old African American male. Pt reported  that since 2012 he started to experience depressive moods described having persistent feeling of sadness and emptiness, accompanied by daily crying episodes, anhedonia described as less interested with hobbies and socialization, and with hypersomnolence. Pt also is having psychomotor agitation ;  can be described as being easily irritable and having emotional distress every days with feelings of ,worthlessness. He is experiencing decreased concentration, fatigue/loss of energy, decreased appetite with weight loss. Patient is having daily recurrent passive suicide without a plan. These symptoms caused impairment with his social and occupational functioning has the patient describes that he isolates himself from friends and family and is being less productive in life and unable to hold down a job. Patient has been experiencing nightmare , flashbacks and re-experiencing unwanted memories.  The patient has been experiencing excessive worry that occurs almost every day . Patient describes his anxiety triggers as restlessness, fatigues with the inability to concentrate , muscle tension in his back and lower jaw , irritability and difficulty sleeping. These symptoms have started since 2012 , after he was deployed to Afghanistan .       .

Past Psychiatric History:

·      General Statement: Patient currently states that he is fine  

·      Caregivers (if applicable):Patient is adult male  , lives alone

·      Hospitalizations: Patient does not have any prior history of being hospitalized for psychiatric issues , however in October 2022 patient states he attempted suicide by drinking himself unconscious . He did not get admitted to any psychiatric hospital after this event.

·      Medication trials: Patient started taking Zoloft , Gabapentin and Prazosin in May 2023.

·      Psychotherapy or Previous Psychiatric Diagnosis : Diagnosed with PTSD 50 percent service related in 2015.  He is attempted psychotherapy in 2020 for 6 months. He did not think it was beneficial.

·      Substance Current Use and History: Patient started to drink alcohol at the age 18, with the  heaviest drinking when he was  20 until present. Per the patient he consumes about 4-5 hard drinks; Patient had black out episode in Oct 2022.

·      Family Psychiatric/Substance Use History: The patient did not disclose any family psychiatric or substance abuse history.

Psychosocial History: Patient is well developed 31 years old male.  He was born and raised in Georgia by both of his parents. Has three brothers and two sisters. No longer has a good relationship with his family. Barely speaks to them. He is currently living alone in an apartment . Currently the patient is unemployed. His last job was has a retail seller in September of 2022. He is an army veteran. He severed in the military from 2010-2015 . He was deployed to Afghanistan multiple times starting 2012. The patient was honorably discharged in 2015. He got married in 2015, but he got divorced in 2022. Patient has no friends that he meets socially. Patient only has high school diploma . He is currently a smoker . Smokes ½ a pack of cigarettes daily.

Medical History:

·      Current Medications: VA hospital prescribed the patient Zoloft 50mg , Prazosin 2mg and Gabapentin 300mg daily in May of 2023. No other current medication or medical diagnosis.

·      Allergies: Patient has no known allergies.

• Reproductive Hz : Patient was born a male . He is currently divorced since 2022. He has no children . 
• Trauma hx: Patient states that he experienced  sexual , physical ,physiological and emotional trauma in his military service starting in the year 2012. 

ROS:

GENERAL: He denies any fevers, chills, fatigue with weight loss.

Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.

SKIN: No rash or itching.

CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.

RESPIRATORY: No shortness of breath, cough, or sputum.

GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.

GENITOURINARY: Burning on urination, urgency, hesitancy, odor, odd color

NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness. No tremors.

HEMATOLOGIC: No anemia, bleeding, or bruising.

LYMPHATICS: No enlarged nodes. No history of splenectomy.

ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.

 

Objective:

Physical exam:

General: Patient is appropriately dressed for the weather, but he is disheveled. She has not done his ADL’s

Neurology :  Speech is clear and coherent . No slurring noted. Patient is alert and orientated time 4. Memory is grossly intact.

Head: Head is normocephalic, atraumatic. No masses on his scalp. Scalera white with pink and moist conjunctive and no discharge. Patient is not missing any teeth. No facial dropping noted.

Respiratory: Breathing is spontaneous, normal rhythm and rate

Cardiac: No edema noted only of extremities. The patient nail beds are pink . Patient has hair equally distributed throughout his upper and lower extremities.

Skin: Patient skin is normal color for ethnicity

Musculoskeletal: Patient gait is steady. He is able to move all extremities . No tremors or shakiness noted when the patient walks or when she extends her hand out.

Diagnostic results:

PHQ-9: Patient was assessed using a PHQ-9 assessment. According to Patel et al , PHQ-9 is the number one screening that providers use to screen for depression(2019). However, this screening tool not only screens the patient for depression , but it also has been proven to be a useful tool to measure the severity of the depression(Patel et al , 2019). The patient scored 22 out 27 on the PHQ-9 . This means that the patient meets criteria for severe depression.

GAD-7: Patient was assessed using a GAD-7. Terlizzi and Villarroel  states the GAD -7 is a validated screening tool that assess the patient’s for the symptoms and severity of generalized anxiety disorder(2020). The patient scored a 21 out 21. Which means that the is experiencing severe symptoms of generalized anxiety disorder.

Assessment:

Mental Status Examination:

Upon examination this patient is well developed 31-year-old African American male. He is alert and orientated and his speech is coherent. However, his speech rate is hesitant and slow. His tone of voices low and apathetic.  He is easily agitated and irritable . His affect is flat. He is withdrawn, and guarded.   His psychomotor movement is increase , he constantly moving his arms and is restless.  His mood is liable. He goes from being depressed to agitated quickly.  

Patient has passive suicidal ideation every day . He does not have an active plan though.  Patient has states that he believes that people are watching him.  He has nightmares about his trauma that he experienced in the military . He has difficulty falling asleep and has multiple nightmares throughout the night. Denies hallucinations or delusions.  He has not done his ADL’s. He is not appropriately dressed for the circumstances. He is all covered up with long sleeves, dark sunglasses, hood on and long pants.  He typically isolates herself. He does not engage in conversion. He is blocking his thought process. Not only does he block his thought process, but his concentration is low.

Differential Diagnoses:

1)    F34.1 Persistent Depressive Disorder with psychotic feature : My primary diagnosis for this patient is Persistent Depressive disorder . This is because according to DSM 5 TR manuel , the patient can have major depressive symptoms , but the length of time must be greater than two years (Psychiatry online , 2022). The patient symptoms have been on going since the 2018 . The he patient has been having a depressive mood , anhedonia , diminished concentration , lack of appetite , mild insomnia . Which means that the patient has meet the criteria for major depressive disorder . However, since his symptoms persistent for more than two years . According to Lyness, in order to give the diagnosis of persistent depressive disorder the patient must meet the criteria for this disorder their depressive symptoms must persist for more than two years(2023). The patient has had his symptoms since 2012 which means he has had his depressive symptoms for about 11 years. Thus, it means that he mostly likely has persistent depressive disorder with psychotic symptoms.

2)    F33.3   Major Depressive Disorder, Recurrent episode, With psychotic features. A differential diagnosis I have for this patient is MDD that recurrent with psychotic features. Rothchild states that patient with this diagnosis will have episode of major depression and also have delusions or hallucinations(2023). The patient is having paranoid delusions that someone is out to get him or watching him. Thus, he is fearful of leaving the house and is paranoid about what people are saying. He also has 5 or nine DSM 5-TR symptoms for major depressive disorder currently. However, the patient states his started in 2012 and does not state that he had a period in the past 11 years where he had not felt the symptoms. Thus , he passes the two year time frame for major depressive disorder . Instead he meets criteria for persistent depressive disorder.

3)    F31.81Bipolar II Disorder Depressive Episode:  A possible differential diagnosis for this patient is Bipolar II Disorder Depressive episode. Bipolar disorder is marked by symptoms of mood fluctuation from depressive to mania(Cichoń et al , 2020).  . Although the patient is currently depressed, he is very easily irritable sometimes. Which could be a manifestation of his depression . However psychiatry online states , in order to have a diagnosis of  bipolar II depressive episode, the patient needs to have at least one history of a hypomanic episode(2022)But he does not have a history or currently display any symptoms for mania or hypomania. Thus, this patient at the time can’t be diagnosed with bipolar type II depressive episode.

 

Treatment Plan :

            The treatment plan for this patient is to increase the Sertraline to 75mg once daily and continue all other medication . Sertraline is SSRI and thus a first line treatment option for depression(Singh and Saadabadi, 2023). However, the medication can take four to eight weeks to be effective (Singh and Saadabadi,2023). The patient has been taking this medication since May, 2023, Thus roughly six weeks . He states that his symptoms are about the same and he does not state that he has had any adverse reactions to the medication. Since the patient PHQ-9 score is 22 out 27 which means he is still severely depressed , we can titrate the medication up from 50mg to 75mg to attempt to alleviate the patient’s symptoms. Also , he is on gabapentin 300mg daily which can be used as anti-anxiety medication or mood stabilization and he is on prazosin 2mg for nightmares. Since he continues to score high on the Anxiety rating and continues to have nightmares . We can continue his other medications.

            The follow up appointment I would recommend for this patient is 2 weeks. By 2 weeks the sertraline so be at it’s full strength to be effective . This means that I would be able to tell if the medication is working the patient.  If not, I can add another type of medication or make other adjustments. Also since I increased his dose , the patient might have potential side-effects on this medication in the 1st two weeks . Thus, his next follow up appointment is two weeks.

            A social determinant for this patient is his current environment and living situation(Social Determinants of Health – Healthy People 2030 | health.gov. ,n.d.). Patient currently is living alone and not interacting with people. This good further deteriorate his mental health . Thus, I would advise him to join veteran group counseling and advise him to other psychotherapy support groups. That way he stops isolating himself and starts interacting with people. Mundar et al states that psychotherapy has been proven beneficial for helping with patient with depressive symptoms(2018). Thus by having him go to psychotherapy the patient can learn technics to further alleviate his depressive symptoms.

Reflections:

            In this case presentation, I am presenting a patient who appeared in the clinic today for her medication side effect. When faced with similar situation the thing I would do differently is I would utilize HAM D scale. The reason why I would use the HAM D scale is to determine how effective his current antidepressant medication is working for her. The patient is currently on Zoloft 50mg daily. He does not like the side effects of this medication. However, I should know if this medication if effective in treating his depression , before making any changes . According to Ashgar et al, HAM-D is considered the golden standard test to examine how efficiently the medication is working for the patient( 2022). If the medication has reduced his depressive symptoms about 50 percent or more than her previous HAM-D exam score , then the medication is effective (Ashgar et al , 2022). Thus , instead of changing the medication , I would need to educate the patient .

            It has not been two weeks since the initial visit yet, so the patient has not come back for a follow up appointment. However, when the patient does follow up with this clinic , then I would question about his current mood , depression and anxiety . I will also ask question about his suicidality. If his mood , depression and anxiety are at the same level or worse , then  I will consider adding another mood stabilizer like Abilify . Mainly because with Abilify , I will be able to treat his psychosis and stabilize his mood . Thus, helping the patient with the liability of his mood and helping to reduce the paranoia. Later down in the line, I would like to address his drinking habits and offer him naltrexone . But currently my priority is stabilizing his mood and decreasing his suicidal thoughts.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

References

Asghar, J., Tabasam, M., Althobaiti, M. M., Ashour, A. A., Aleid, M. A., Khalaf, O. I., & Aldhyani, T. H. H. (2022). A Randomized Clinical Trial Comparing Two Treatment Strategies, Evaluating the Meaningfulness of HAM-D Rating Scale in Patients With Major Depressive Disorder. Frontiers in Psychiatry, 13. https://doi.org/10.3389/fpsyt.2022.873693

Cichoń, L., Janas-Kozik, M., Siwiec, A., & Rybakowski, J. K. (2020). Clinical picture and treatment of bipolar affective disorder in children and adolescents. Psychiatria Polska, 54(1), 35–50. https://doi.org/10.12740/pp/onlinefirst/92740

Lyness, J. (2023). Unipolar depression in adults: Assessment and diagnosis. Up To Date. https://www.uptodate.com/contents/unipolar-depression-in-adults-assessment-and-diagnosis?topicRef=16596&source=see_link#H1

Munder, T., Flückiger, C., Leichsenring, F., Abbass, A., Hilsenroth, M. J., Luyten, P., Rabung, S., Steinert, C., & Wampold, B. E. (2018). Is psychotherapy effective? A re-analysis of treatments for depression. Epidemiology and Psychiatric Sciences, 28(03), 268–274. https://doi.org/10.1017/s2045796018000355

Patel, J., Oh, Y. H., Rand, K. L., Wu, W., Cyders, M. A., Kroenke, K., & Stewart, J. C. (2019). Measurement invariance of the patient health questionnaire‐9 (PHQ‐9) depression screener in U.S. adults across sex, race/ethnicity, and education level: NHANES 2005–2016. Depression and Anxiety, 36(9), 813–823. https://doi.org/10.1002/da.22940

Psychiatry online. (2022). Depressive Disorders. American Psychiatric Association Publishing EBooks. https://doi.org/10.1176/appi.books.9780890425787.x04_depressive_disorders

Rothchild, A. (2023). Unipolar major depression with psychotic features: Maintenance treatment and course of illness. Up To Date. https://www.uptodate.com/contents/unipolar-major-depression-with-psychotic-features-maintenance-treatment-and-course-of-illness#:~:text=Unipolar%20major%20depression%20with%20psychotic%20features%20is%20a%20severe%20subtype,guilt%20and%20worthlessness%20%5B3%5D.

. Singh, H. K., & Saadabadi, A. (2023). Sertraline. Stat Pearls. https://pubmed.ncbi.nlm.nih.gov/31613469/#full-view-affiliation-2

Social Determinants of Health – Healthy People 2030 | health.gov. (n.d.). Retrieved June 20,2023. from https://health.gov/healthypeople/priority-areas/social-determinants-health

Terlizzi, E., & Villarroel, M. A. (2020). Symptoms of Generalized Anxiety Disorder Among Adults: United States, 2019. NCHS Data Brief, 378, 1–8. https://pubmed.ncbi.nlm.nih.gov/33054928/#:~:text=The%20GAD-7%20scale%20is%20a%20validated%20brief%20selfreport,have%20mild%2C%20moderate%2C%20or%20severe%20symptoms%2C%20respectively%20%282%29.