34 yo, AA female referred to you by her Primary Care APRN. Married with 3 children. ( 8yo son, 6 yo daughter, and 4 yo son). Has a Masters’ degree in Human Resources and worked for energy company.
First visit with PMHNP for diagnostic evaluation at the Outpatient Community Mental Health Clinic.
“ I’ve been having some back pain and saw my Primary Care Provider/APRN but she can’t seem to find anything wrong with my back……She had started me on Prozac about a year ago but I can’t remember when I last felt good… I used to enjoy my life and my children. It has to be 3 years ago before my youngest was born that I’ve been feeling this way. Plus, I haven’t gone back to work…and with three kids it takes two incomes…so, I feel bad about that.”
History of Present Illness:
Maria scheduled an appointment with you after the urging of her family and Primary Care APRN. She relates that they have been pressuring her to “do something”. “I think they have gotten just too fed up with me because I’m just not the same person I used to be.” She reports that she has not returned to work after her last pregnancy and instead is a “stay at home mom” and expresses worry about family finances with three kids. “But, my husband makes good money as the Superintendent of schools and assures me I need to take care of myself first, which helps my worry.” She relates that even though she is sleeping more than 10 hours a night she still endorses ongoing fatigue and typically wakes up about 3AM but goes back to sleep after 30 minutes. She reports she used to “be a runner but now all I do is watch the kids. I never lost all of my post baby weight but now I have gained another 30 pounds over the last couple of years. I used to have a big garden every year because I want the kids to learn good habits for eating but, the yard doesn’t look like it used to and I haven’t put in a garden for the last couple of summers now”. She really enjoyed her job and had worked there for over 10 years. She has lost contact with many of her co-worker friends and reported her coworkers “wouldn’t recognize me now because of the weight.” “I used to make decisions constantly with my work now I can’t even decide what to fix for dinner…I just don’t think this is ever going to get better.” “I would never do anything to hurt myself….I have my kids, my husband, my family and my faith in God. But, sometimes, I’ll just think of it (suicide) and I’m not sure why….I’ve never thought of how I’d hurt myself…but, it just seems to pop in my mind.”
Past Psychiatric History:
Maria reports that she had an episode of depression prior to getting married 10 years ago. She was started on an antidepressant but she doesn’t recall the medication which she took for about 6 months and was in therapy for the same time period. She reports no additional treatment for psychiatric illness or psychiatric hospitalizations. She denies manic episodes, psychotic sx, panic attacks, obsessions or compulsions or any hx of alcohol or drugs.
Maria reports that she is “really healthy except for this weight.” She denies any chronic or acute illness except for some diffuse back pain. Medications: Prozac 20 mgs po q AM, Daily Multivitamin. She has an IUD for birth control. She reports her periods are regular but she has heavier periods since she had the IUD inserted a year ago. All 3 children vaginal deliveries without medical complications. NKDA.
Family Medical History:
Maria reports both of her parents are living and in good health and are supportive of her. She is the middle child and has an older and a younger sister. Both of her sisters are reported as being in good health a well.
Family Psychiatric History:
Father- no history, Mother history of depression and takes an antidepressant-Effexor XR problems.
Born and raised in Philadelphia, PA. Middle child of three sisters. Has regular contact with her entire family and enjoys holidays with them. Attended grade school, middle school and high school in Philadelphia and was in the honor society. Participated in ballet and archery in school. Immediately after finishing her bachelor’s degree in social work, started on her Masters’ degree in Human Resources. Has worked for the energy company for about 10 years as the Director of Human Resources. Married for about 10 years and describes the relationship as good. Has three healthy children. Used to exercise regularly (running) but has not for the last few years. Usually drinks 2 cups of coffee in the AM and one diet Pepsi (16.9 fl oz.) the remainder of the day. Has never smoked. Denies any illegal substances ever. Glass of white wine at Christmas but no other alcohol. No legal issues. Consumes a regular diet without restrictions. Attends Baptist church regularly.
Medical Review of Systems:
General: Endorses gradual weight gain, c/o some fatigue.
Integumentary: Denies rashes, sores, changes in skin or moles.
Endocrine: Denies hx of goiter. Denies polyuria, polydipsia. c/o fatigue
Hematologic: Denies easy bruising or bleeding, No past infusions.
Musculoskeletal: c/o diffuse back pain, mostly in upper shoulders
Neurological: denies fainting, blackouts, seizures, tremors, involuntary
Breast: Denies lumps, pain, discharge.
Neck: Denies lumps, swollen glands, goiter, pain or stiffness
Mouth/throat: Denies problems with teeth or gums, sores, dry mouth,
Nose/sinuses: Denies frequent colds, nasal stuffiness, discharge, itching,
Ears: Denies hearing loss, tinnitus, vertigo, earaches, infections
Eyes: Denies vision problems, glaucoma, cataracts, eye surgery
Head: Denies head injury, dizziness, lightheadedness
Respiratory: Denies shortness of breath, wheezing, cough, sputum production, hemoptysis, asthma
Cardiac: Denies chest pains, palpitations, murmurs, abnormal EKG, edema
GI: Denies hx of GERD, abdominal pain, N/V/D, constipation, black tarry stools, gallbladder trouble, jaundice, hemorrhoids
Neurologic: Denies numbness, paresthesia, weakness
GU: Denies frequency, urgency, burning, bloody urine, incontinence, Uses IUD. Periods are “heavier”
Vaccine status: Flu shot for recent, Did not get pneumonia shot, UTD on all other immunizations including Tetnaus.
Vital Signs:Ht: 5’7”, Wt: 210 lbs, BP 118/60, Pulse, 82, Resp 16, Temp 98.2. Waist circumference: 38 inches
MSE/Observations: Maria is a 34 yo appearing, AA female sitting in the chair erect and appears slightly anxious. She is alert and oriented to person, time, place, and situation. Neatly dressed in clean pressed khakis pants and floral pinkish blouse appropriate for the temperature/weather. Well groomed dark black hair and has lipstick in place. Wearing a wedding ring and small hooped ear rings. Has good eye contact during interview questions, concentration is intact; no outward physical abnormalities. Attitude: pleasant, cooperative, and friendly. Motor: Ambulates with even gait, steady. Speech: clear, normal, rate, volume, tone, and amount. Articulate and Spontaneous however some increased latency when asked about past events. Mood: “just not myself”. Affect: depressed, blunted. Thought process: Coherent, logical, linear, and goal directed. Thought Content: “haven’t been myself”. Focuses on what her life used to be like versus what it is now. Denies SI/HI. Denies auditory visual, olfactory, and tactile hallucinations. Some controlled worry about finances. Denies hx of mania or hypomania, denies obsessions or compulsions. Denies history of panic attacks. Denies ETOH or drugs. Insight/ Judgment: Good. Intellect: Well above average. Calculated $5.50 – $1.50 with a result of $4. Memory: Objects 3/3. Recent and remote intact.
Using your Carlat& DSM5 texts and other relevant sources to develop your clinical impression.
1. Create a concept map, table, or decision tree to help you identify all relevant psychiatric and medical conditions you would consider for this individual. Include the DSM5 criteria for psychiatric diagnoses.
2. From the above, create a prioritized list of your top 3 differential psychiatric diagnoses, starting with the primary working diagnosis (your answer), include the ICD 10 diagnostic code for each diagnosis. Explain your thinking process on what factors you considered that led you to select your primary diagnosis, and other possible diagnoses.
3. List 2 most pertinent interview questions for each of the 3 differential psychiatric diagnoses that you need to ask to rule in or rule out that diagnosis.
4. List 2 most pertinent differential medical conditions you would consider for this individual. Provide a brief list of symptoms that support your medical differentials.
5. List any pertinent laboratory tests or screening tools you might use to help you rule in or rule out your top 3 differential diagnoses and a concise rationale statement.
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