Psychiatric Evaluation discussion post.Replayin to Nadine’s post.
Patient ID: S.N.
DOB: 9/29/2006
Sex: F
Encounter
Date: 01/31/2023
Encounter Type: Office Visit
SUBJECTIVE:
CC: “feeling sad and anxious”
HPI:
Patient is a 16 yo female seen in person along with her mother, J., for an evaluation at the clinic. Her pediatrician referred her for symptoms of depression and anxiety. Patient states that she cries consistently, on a daily basis; she has no motivation and desire to do anything. She reports lack of sleep and appetite, constant worries and vivid nightmares. She says she has felt like that the past two months after she was expelled from her High school. She says her passing grade was unmet for only 1 point. She says she started going to another High school, but she has been feeling uncomfortable, sad, anxious, and unable to focus. When she was asked what will make her feel happy; she replies, “Going back to my previous high school will make me feel better and happy”. Currently, she complains of depressed mood and anxiety. She sleeps poorly, and her appetite is poor. Mood is “depressed” all the time. She rates depression at 8/10; PHQ-9: 12/27, GAD-7:14/21 and MDQ: 3/13. She endorses moderate depression at present, poor concentration, low energy level, no motivation, low self-esteem, guilty feeling, severe anhedonia. She denies manic symptoms, denies any anger or aggression, endorses feelings of hopelessness, worthlessness and helplessness. She denies any thoughts of self harm at present, denies any anger or aggression, denies any suicidal or homicidal ideations at present, denies any auditory or visual hallucinations at present. No evidence of paranoia or delusions. There are some symptoms of anxiety but no panic attacks and no symptoms of social phobia or OCD. She contracts for safety at present and denies any thoughts of self harm.
Past Medical History:
Denies any medical problems. No h/o head injuries or seizure or any Cardiac problems.
Surgical History: Denies.
Gynecological History: Sexually inactive
Family History: Mother with Hypertension; Father: Denies; Siblings: denies
Social History: Education:
Female, sophomore, has a boyfriend for 4 years and good relationship
-Living with 2 young siblings, parents, and maternal grandmother, good situation
-Parents are alive and married
-Has history of past bullying but does not affect her.
Smoking Status:
Never Smoked; denies drinking, illegal drugs
-Current Medications: Vitamins OTC
Past Psychiatric History:
Patient denies any h/o self harm behaviors, suicide attempts or hospitalizations.
Review of System:
Constitutional: Sad/anxious/poor focusing/poor sleep & appetite
Legal History: no current legal issues
Abuse History:
Denies any history of physical, emotional or sexual abuse.
Substance History: Denies any history of smoking cigarettes, drinking alcohol or any use of illegal drugs.
OBJECTIVE:
Height: 64.00 in
Weight: 125.00 lbs
BMI: 21.45
Mental Status Exam: Appearance: Mixed Jamaican & Caucasian female, with direct eye contact, cooperative; sitting in upright position without tension. She is casually dressed with clean clothes, appropriate to age, fit, season and occasion. Her speech is Low/Soft rate and volume. She describes her mood as sad/anxious and her affect is flat, congruent with her mood. Her thought process is linear; no disturbances noted. No delusions or paranoia noted. She is Alert, Fully Oriented x 3 with intact remote and recent memory. She has fair insight and judgement; she denies suicidal or homicidal ideas.
ASSESSMENT:
Diagnosis:
F4323; Adjustment disorder with mixed anxiety and depressed mood
Adjustment disorder: Adjustment disorder is a reaction to a combination of stressful life situation, ongoing psychological difficulties that usually appear within a month of the occurence of the stressor and disappears within six months unless the stressors remain (Menachem et al., 2018)
Differential diagnosis:
F33.1: Major depressive disorder, recurrent, moderate.
Depression is one of the most commonly diagnosed mental disorders in children, according to the Centers for Disease Control and Prevention (Laurel, 2022). Teen depression affects the way they behave, feel and think. It can also cause physical, emotional and functional problems.
F41.9: Anxiety Disorder, Unspecified. Anxiety is a common mental health disorder and is characterized by excessive worry or fear that usually present at physical and emotional symptoms (Mangione et al., 2022). A national survey done between 2018-2019 revealed that about 7.8% kids aged 3 to 17 suffer from some type of anxiety disorder (Mangione et al., 2022). If not resolved early, it may lead to future anxiety and depression in adulthood (Centers for Disease Control, 2023, Mangione et Al., 2022).
PLAN:
Medication:
Zoloft (Sertraline HCl) 25 MG Oral Tablet; Take 1 tablet orally daily; Qty: 15; Refills: 0
Psychotherapy:
CBT recommended
Medication education:
Take your medication as prescribed.
-Sertraline: is a selective serotonin reuptake inhibitor (SSRI) that works in the brain by blocking the recycling of released serotonin back into the nerve endings; by doing so, it increases the level of serotonin in the brain (Epocrates, 2023). Serotonin along with dopamine are known neurotransmitters that play a role in our mood, sleep, the way we feel about ourselves. They are first line treatment for anxiety and depression. Side effects may include insomnia, change in appetite, weight gain, sweating, sexual dysfunction, nausea/vomiting, dizziness, headache, diarrhea, nervousness (Epocrates, 2023).
Black box warning: Increased suicidal thinking in adolescents and children.
Crisis planning: Compliance issues discussed today with patient and her mother. Patient’s mother is advised to continue to see patient’s pediatrician and specialists for medical care as needed. Monitor and practice sleep hygiene, monitor weight, appetite and behavioral changes. In case of emergency or if patient is experiencing homicidal or suicidal thought, patient’s mother is advised to call 911 or go to the nearest hospital. If any allergic reaction to the medications occur, call the office or go to the nearest ER.
Monitor side effects of the medications and Follow up appointment in 2 weeks.
Signature/credentials:
Nadine, Massillon, MSN, FNP-C, PMHNP-S
References
Centers for Disease Control and Prevention (2023). Anxiety and Depression in Children. Retrieved from https://www.cdc.gov/childrensmentalhealth/depression.html
Epocrates (2023). Zoloft. Retrieved from https://online.epocrates.com/drugs/266208/Zoloft/Patient-Education
Laurel, K. (2022). Consumer Health: Teens and depression: a back-to-school concern. Mayo Clinic News Network; Rochester.
Mangione, C., Barry, M. & Nicholson, J. (2022). Screening for Anxiety in Children and Adolescents US Preventive Services Task Force Recommendation Statement. Journal of the American Medical Association, (328), 14
Menachem, B., Mahat-Shamir, M., Lorenz, L. & Osnat, L.(2018). Screening of adjustment disorder: Scale based on the ICD-11 and the Adjustment Disorder New Module. Journal of Psychiatric Research,103, 91-96
