NR 603 Week 6 Mental Health Disorders
Include their actual chief complaint, demographic data, HPI, PMHX, PSHX, medications,
allergies, subjective and objective findings without identifying the patient’s name.
Dr. Deering and class,
The following information is in regards to a patient with a mental health disorder:
Subjective:
Chief Complaint: Difficulty sleeping and fatigue
HPI:
D.W is a 32 year old female who presented to the office three weeks ago with
complaints of difficulty sleeping and fatigue. She reported that it takes her several hours to
fall asleep and that some nights she could not fall asleep at all. She stated that she spends
a lot of time worrying about work deadlines and taking care of her family. She and her
husband divorced a month ago, and she is currently taking care of her four-year old twin
daughters with the help of her mother. She works as a human resources recruiter. She
reports little interest in hobbies that she used to love, including playing golf and soul cycling.
She states that she’s been having very low energy, tired, and difficulty concentrating in the
last few weeks. She tries to do at least one social activity with her friends, but most nights
she feels too tired. She also finds that social events with couples make her feel very sad
and uncomfortable. She has not tried any prescription or over-the-counter medications.
Current medications: Multivitamin and metoprolol 25 mg once daily
Allergies: Pollen
PMHx: Hypertension
PSHX: Cesarean delivery in 2015
Social history: Divorced with four-year old twin daughters. Denies tobacco use or
recreational drug use. Drinks three cups of coffee daily. Drinks one to two glasses of wine in
one month.
ROS:
General: Denies fever, chills, or night sweats. Reports fatigue and inability to sleep in the
past three weeks. Reports unintentional weight loss of 5 pounds in the last month.
HEENT: Denies head trauma, visual loss, hearing loss, tinnitus, sore throat, or hoarseness.
Neuro: Denies headaches, dizziness, seizures, vertigo, loss of balance, or incoordination.
,Cardiovascular: Denies chest pain, palpitations, or peripheral edema.
Respiratory: Denies dyspnea, wheezing, shortness of breath, cough, or hemoptysis.
Gastrointestinal: Reports decreased appetite in the last month. Denies nausea, vomiting,
diarrhea, constipation, or abdominal pain.
Genitourinary: Denies dysuria, nocturia, hematuria, or vaginal discharge. Currently on
menstrual period.
Hematologic: Denies easy bruising or bleeding.
Psychiatric: Reports inability to sleep, difficulty concentrating, and excessive worrying.
Denies a history of depression or family history of other psychiatric disorders. Denies
hallucinations, delusions, or suicidal thoughts.
Objective:
Vital Signs: HR 92, BP 122/72, RR 16 (regular). Height: 5’5; Weight: 144 lbs
General: D.W appears fatigue but is in no respiratory distress. She is awake, alert,
cooperative, and dressed appropriately.
HEENT: Head is normocephalic. No exudate noted in the eyes. No vision loss or blurred
vision. Bilateral TMs are pearly gray. No hearing loss noted. Patent nares with no exudate.
Moist and intact oropharynx. Neck is supple. No cervical lymph node tenderness and
lymphadenopathy. Midline thyroid without enlargement and masses.
Cardiovascular: S1 and S2 with regular rate and rhythm. No murmurs or rubs noted.
Respiratory: Symmetric chest expansion. Unlabored respirations. Lung sounds clear
bilaterally. No crackles or wheezes noted.
Psych: PHQ-9 score is 14. Speech is clear. Able to express thoughts in a logical manner.
Diagnostic or Lab results:
Available lab results drawn last month during D.W’s annual physical:
RBC 4.5 million/ mcL; Hgb 13.2 g/dL; HCT 37%; PLT 256,000; WBC 7,000 mc/L; Na 143
mEq/L; K 4.2 mEq/L; Mg 2.0 mEq/L; HCO3 24 mEq/L; BUN 10 mg/dL; Creatinine 0.7 mg/dL
TSH: 2.31, Free T4 0.9 ng/dL, Cholesterol: TC- 190 mg/dl, LDL- 97 mg/dl, VLDL- 36 mg/dl,
HDL- 43 mg/dl, triglycerides- 100 mg/dl
Vitamin B12: 300 ng/ml
Vitamin D: 22 ng/ml
, Part 2: Treatment Plan
Major depressive disorder (MDD) is considered one of the top reasons for disability in the
United States (WHO, 2018). Depression affects 350 million people worldwide. It is more
prevalent in women than men. This disorder can go undetected for many years, often
leading to increased morbidity from other physical illnesses, substance abuse, and
increased suicidal ideations.As healthcare providers, it is important to conduct a complete
history and physical, and use appropriate screening tools, such as PHQ-9, to diagnose
depression. While many concerning histories should be referred to a mental health
specialist, healthcare providers can certainly initiate treatment to help alleviate their
symptoms. Keeping an open line of communication with patients who suffer from
depression will positively impact their lives and reduce the social stigma associated with
MDD. The following information is the full five-point treatment plan and analysis for D.W’s
plan of care.
Primary Diagnosis: Major Depressive Disorder, first episode
Diagnostic Testing: At this time, it is important to rule out medical conditions and
medication regimens that may contribute to D.W’s symptoms. Unfortunately, there is no
diagnostic testing for major depressive disorder (MDD). The guidelines from the American
Psychiatric Association (APA, 2017) recommends a comprehensive physical examination,
as well as a thorough review of medical history, medications, life stressors, and the
presence of substance use disorder. D.W does not have medications or history of
substance use that may contribute to her symptoms. She also does not have any family
history of psychiatric disorders. However, D.W does have a couple life stressors. She was
recently divorced a month ago, and is now the sole caretaker of her twin daughters. She
also reports having increased stress with work deadlines as a human resources recruiter.
The APA also recommends ruling out differential diagnoses that may mimic D.W’s
depressive symptoms (APA, 2017). Therefore, the next valid step is to obtain laboratory
tests, including complete blood count (CBC), comprehensive metabolic panel (CMP),
thyroid-stimulating hormone (TSH), lipid panel, vitamin B12, and vitamin D levels.
Assessment and screening must include a work-up to exclude other disorders, such as
hypothyroidism, anemia, renal problems, cancers, or cardiac issues, that may cause similar
symptoms (APA, 2017).
Once differential diagnoses have been addressed, utilizing the patient health questionnaire
(PHQ) tool is the next step in D.W’s assessment. According to the US Preventive Services
Task Force (USPSTF), the PHQ screening tool is one of the most common, non-invasive
screening tools that can be performed to measure the severity of depression (Maurer,
Raymond, & Davis, 2018). The PHQ can be an important tool to monitor and address the
patient’s potential for uncontrolled depression because it encompasses a combination of the
DSM-IV criteria for depression. If D.W’s screening is indicative of depression, another
essential step is to confirm diagnosis by using the DSM-IV criteria for depression (Whooley,
2016). In addition to depressed mood or anhedonia in the past two weeks, at least five of
Include their actual chief complaint, demographic data, HPI, PMHX, PSHX, medications,
allergies, subjective and objective findings without identifying the patient’s name.
Dr. Deering and class,
The following information is in regards to a patient with a mental health disorder:
Subjective:
Chief Complaint: Difficulty sleeping and fatigue
HPI:
D.W is a 32 year old female who presented to the office three weeks ago with
complaints of difficulty sleeping and fatigue. She reported that it takes her several hours to
fall asleep and that some nights she could not fall asleep at all. She stated that she spends
a lot of time worrying about work deadlines and taking care of her family. She and her
husband divorced a month ago, and she is currently taking care of her four-year old twin
daughters with the help of her mother. She works as a human resources recruiter. She
reports little interest in hobbies that she used to love, including playing golf and soul cycling.
She states that she’s been having very low energy, tired, and difficulty concentrating in the
last few weeks. She tries to do at least one social activity with her friends, but most nights
she feels too tired. She also finds that social events with couples make her feel very sad
and uncomfortable. She has not tried any prescription or over-the-counter medications.
Current medications: Multivitamin and metoprolol 25 mg once daily
Allergies: Pollen
PMHx: Hypertension
PSHX: Cesarean delivery in 2015
Social history: Divorced with four-year old twin daughters. Denies tobacco use or
recreational drug use. Drinks three cups of coffee daily. Drinks one to two glasses of wine in
one month.
ROS:
General: Denies fever, chills, or night sweats. Reports fatigue and inability to sleep in the
past three weeks. Reports unintentional weight loss of 5 pounds in the last month.
HEENT: Denies head trauma, visual loss, hearing loss, tinnitus, sore throat, or hoarseness.
Neuro: Denies headaches, dizziness, seizures, vertigo, loss of balance, or incoordination.
,Cardiovascular: Denies chest pain, palpitations, or peripheral edema.
Respiratory: Denies dyspnea, wheezing, shortness of breath, cough, or hemoptysis.
Gastrointestinal: Reports decreased appetite in the last month. Denies nausea, vomiting,
diarrhea, constipation, or abdominal pain.
Genitourinary: Denies dysuria, nocturia, hematuria, or vaginal discharge. Currently on
menstrual period.
Hematologic: Denies easy bruising or bleeding.
Psychiatric: Reports inability to sleep, difficulty concentrating, and excessive worrying.
Denies a history of depression or family history of other psychiatric disorders. Denies
hallucinations, delusions, or suicidal thoughts.
Objective:
Vital Signs: HR 92, BP 122/72, RR 16 (regular). Height: 5’5; Weight: 144 lbs
General: D.W appears fatigue but is in no respiratory distress. She is awake, alert,
cooperative, and dressed appropriately.
HEENT: Head is normocephalic. No exudate noted in the eyes. No vision loss or blurred
vision. Bilateral TMs are pearly gray. No hearing loss noted. Patent nares with no exudate.
Moist and intact oropharynx. Neck is supple. No cervical lymph node tenderness and
lymphadenopathy. Midline thyroid without enlargement and masses.
Cardiovascular: S1 and S2 with regular rate and rhythm. No murmurs or rubs noted.
Respiratory: Symmetric chest expansion. Unlabored respirations. Lung sounds clear
bilaterally. No crackles or wheezes noted.
Psych: PHQ-9 score is 14. Speech is clear. Able to express thoughts in a logical manner.
Diagnostic or Lab results:
Available lab results drawn last month during D.W’s annual physical:
RBC 4.5 million/ mcL; Hgb 13.2 g/dL; HCT 37%; PLT 256,000; WBC 7,000 mc/L; Na 143
mEq/L; K 4.2 mEq/L; Mg 2.0 mEq/L; HCO3 24 mEq/L; BUN 10 mg/dL; Creatinine 0.7 mg/dL
TSH: 2.31, Free T4 0.9 ng/dL, Cholesterol: TC- 190 mg/dl, LDL- 97 mg/dl, VLDL- 36 mg/dl,
HDL- 43 mg/dl, triglycerides- 100 mg/dl
Vitamin B12: 300 ng/ml
Vitamin D: 22 ng/ml
, Part 2: Treatment Plan
Major depressive disorder (MDD) is considered one of the top reasons for disability in the
United States (WHO, 2018). Depression affects 350 million people worldwide. It is more
prevalent in women than men. This disorder can go undetected for many years, often
leading to increased morbidity from other physical illnesses, substance abuse, and
increased suicidal ideations.As healthcare providers, it is important to conduct a complete
history and physical, and use appropriate screening tools, such as PHQ-9, to diagnose
depression. While many concerning histories should be referred to a mental health
specialist, healthcare providers can certainly initiate treatment to help alleviate their
symptoms. Keeping an open line of communication with patients who suffer from
depression will positively impact their lives and reduce the social stigma associated with
MDD. The following information is the full five-point treatment plan and analysis for D.W’s
plan of care.
Primary Diagnosis: Major Depressive Disorder, first episode
Diagnostic Testing: At this time, it is important to rule out medical conditions and
medication regimens that may contribute to D.W’s symptoms. Unfortunately, there is no
diagnostic testing for major depressive disorder (MDD). The guidelines from the American
Psychiatric Association (APA, 2017) recommends a comprehensive physical examination,
as well as a thorough review of medical history, medications, life stressors, and the
presence of substance use disorder. D.W does not have medications or history of
substance use that may contribute to her symptoms. She also does not have any family
history of psychiatric disorders. However, D.W does have a couple life stressors. She was
recently divorced a month ago, and is now the sole caretaker of her twin daughters. She
also reports having increased stress with work deadlines as a human resources recruiter.
The APA also recommends ruling out differential diagnoses that may mimic D.W’s
depressive symptoms (APA, 2017). Therefore, the next valid step is to obtain laboratory
tests, including complete blood count (CBC), comprehensive metabolic panel (CMP),
thyroid-stimulating hormone (TSH), lipid panel, vitamin B12, and vitamin D levels.
Assessment and screening must include a work-up to exclude other disorders, such as
hypothyroidism, anemia, renal problems, cancers, or cardiac issues, that may cause similar
symptoms (APA, 2017).
Once differential diagnoses have been addressed, utilizing the patient health questionnaire
(PHQ) tool is the next step in D.W’s assessment. According to the US Preventive Services
Task Force (USPSTF), the PHQ screening tool is one of the most common, non-invasive
screening tools that can be performed to measure the severity of depression (Maurer,
Raymond, & Davis, 2018). The PHQ can be an important tool to monitor and address the
patient’s potential for uncontrolled depression because it encompasses a combination of the
DSM-IV criteria for depression. If D.W’s screening is indicative of depression, another
essential step is to confirm diagnosis by using the DSM-IV criteria for depression (Whooley,
2016). In addition to depressed mood or anhedonia in the past two weeks, at least five of
