Complex Case Study Critic 2

Learning Goal: I’m working on a nursing multi-part question and need an explanation and answer to help me learn.

Objectives:

• Understand the fundamentals between depressive symptoms and diagnosis in children/adolescents
• Identify the overlap of depression and anxiety in the adolescent population
• Apply evidence-based research about medication treatment of childhood or adolescent depression disorders
• Develop a treatment plan specific to an adolescent experiencing depressive or anxiety symptoms

Subjective:

CC (chief complaint): “There has been a lot going on, but I won’t hurt myself.”

HPI: G.W. is a 12-year-old female who presents with symptoms of worthlessness, guilt, panic, chest tightness, and expressed suicidal ideation with self-injurious behaviors.The patient is seen with her mother for psychiatric evaluation following a 5-day inpatient hospitalization.She denies suicidal or homicidal ideation during intake, denies auditory or visual hallucination.She reports recent suicidal ideation with plan to hang herself which was the reason for her hospitalization, but states “it was all a misunderstanding”. She reports a history of cutting via scissors for over one year; reports last incident was one month ago. Was unable to provide frequency when most acute but reported she cuts when feeling stressed, punished, or overwhelmed at home or school. The patient endorses depressive symptoms of hypersomnia, negative view of self, hopelessness, helplessness, worthlessness, guilt, and passive suicidal ideation stating she thinks about what it would be like if she “was not here or alive anymore”. She reports poor appetite and poor concentration or focus while in class. Patient identified no concerns regarding completion of ADLs and identified that she does well taking care of herself. Patient additionally noted experiencing excessive worry, hypervigilance, panic attacks, over-thinking and impulsivity as symptoms related to anxiety and panic – mother attested to this, also.

Substance Current Use: Patient has no known history of substance abuse and other addictive behaviors.

Familial Psychiatric History:Depression in mother, anxiety in older sister. No other familial psychiatric history reported or known.No relevant familial or personal medical history reported.

Medical History:

• Current Medications: Supplemental Vitamin B6 2mg daily
• Allergies: NKDA.

• Reproductive Hx: Patient reports abstinence from intercourse. No known reproductive history.Per patient “the only thing I know is my parents used to tell me I wet the bed until I was 10 years old.It happens sometimes now, too.” Positive for nocturnal enuresis.

ROS:

• GENERAL: Denies recent illness, fever, or chills. Denies any recent change in weight or appetite.
• HEENT: Eyes: denies visual loss, blurred vision, double vision or yellow sclera. Ears: denies having any pain or discharge, denies hearing changes.Nose, throat: denies headache, no reported complaints of congestion or runny nose; denies sore throat.
• SKIN: Bruising noted, scarring present r/t cutting history on b/l forearms and inner thighs.No known urticaria, no lesions.
• CARDIOVASCULAR: Reports chest pressure/ tightness, reports heart burn intermittently; denies chest pain, denies edema or heart palpitations.
• RESPIRATORY: Denies cough, reports shortness of breath.
• GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea.No abdominal pain or blood present.
• GENITOURINARY: Denies buring on urination, urgency, hesitancy, frequency or nocturnal enuresis.Denies odor or odd color.
• NEUROLOGICAL: Negative for headache, dizziness, syncope, or numbness/tingling.Denies any changes in bowel control. Reports occasional nocturnal enuresis.
• MUSCULOSKELETAL: denies muscle or joint pain/stiffness.
• HEMATOLOGIC: No evidence of anemia, bleeding or bruising; denies frequent bleeding or bleeding of gums
• LYMPHATICS: denies enlarged nodes.
• ENDOCRINOLOGIC: Denies excessive hunger or thirst.

Physical exam:

VS: Temp: 97.1; BP 110/68; RR 17; P 65; HT 5’4”; WT 150lbs

• General: Patient is alert and oriented to person, place, time, and situation. G.W. appears her stated age.Patient appears well nourished and well kept. Skin is unremarkable, with exception to wounds/cuts from past cutting and bruising.Pupils PERRLA.Neurological exam normal – patient able to answer orientation questions appropriately.

• Head: Patient’s facial features symmetric; no tics, tremors, or drooping. Normal and full range of motion of neck and head; symmetric in region. Neck: no masses or palpable lymph nodes. Negative for gross abnormalities to thyroid gland. Ears: Patent, transparent grey tympanic membrane, negative for erythema. Eyes: Clear sclera, no discharge present; patient’s pupils equal and reactive to light. Nose: Both naris patent with septum intact, no deviation or bleeding noted. No rhinorrhea noted. Throat: Pink with no erythema noted. No postnasal drainage.
• Heart: RRR, no murmurs. S1, S2 audible, no edema
• Lungs: CTA, chest wall symmetrical. No adventitious breath sounds noted.
• Abd: soft and hyperactive bowel sounds; negative for pain with palpation of all quadrants, no distension noted.
• Skin: Pigmentation is pale.No lesions, abrasions; bruising noted.
• Rectal exam: No sores, lesions, or rashes.

Objective:

Diagnostic results:

• Vital signs (assess blood pressure, heart rate, respirations, temperature and height/weight) – normal versus abnormal? do these match her appearance?
• EKG for cardiac monitoring (assess QT), rule out abnormalities
  • Specifically need EKG for baseline for medications
• Possible CT scan and MRI to rule out brain abnormalities/ psychosis
• Laboratory diagnostics
  • Thyroid hormone/function; Check LFT’s, toxicology screenings, CBC and thyroid function tests, CT scan; Hemoglobin a1c – metabolic monitoring
  • CMP- assess electrolytes/imbalances that may be contributing to her mood or sleep
  • Liver function testing/kidney function to assess absorption and secretion
• To understand patient’s mood-mood disorder questionnaire; identify suicidal behaviors with suicidal behaviors questionnaire revised, Columbia Suicide Severity Rating Scale (revealed no risk); Depression screenings to confirm or reject diagnosis (i.e., phq9, Beck Depression Inventory, Hamilton’s depression rating scale)
• anxiety disorder- GAD7, Beck’s anxiety scale, Hamilton’s anxiety scale, and Zung’s self-rating anxiety

Assessment:

Patient is an 12-year old female who presents looking her stated age. The patient is cooperative during the assessment and answers all questions appropriately. Patient aox4 (person, place, time and situation). Patient appears well-nourished and well-kept, there is no evidence of abnormal activity. Patient denies suicidal or homicidal thoughts, denies auditory or visual hallucinations.No evidence of delusional thinking. Patient with clear and logical speech, no tics or self-injurious behaviors noted. Patient is alert and oriented, recent and remote memories in tact. Concentration is appropriate, there is no evidence of looseness of association or flight of ideas.Patient’s mood is flat, affect is appropriate to mood.Patient’s judgement and insight intact and age appropriate.

Mental Status Examination:

Diagnostic Impression:

• Major depressive disorder (f32.9)- G.W. presents feeling depressed, with poor sleep and poor appetite. She is intermittently tearful during the intake and endorses depressive symptoms of poor sleep, appetite and concentration, low energy and feelings of guilt related to “making my family go through this because of me”.Patient presentation consistent with DSM-5 diagnostic criteria of depression includes symptoms of hypersomnia, negative view of self, hopelessness, helplessness, worthlessness, and passive suicidal ideation stating she thinks about what it would be like if she “was not here or alive anymore”. To understand how she is feeling, we can use the mood disorder questionnaire, and depression screenings to differentiate and evaluate the severity of her depressive symptoms (i.e.,Beck Depression Inventory and Hamilton’s depression rating scale).Also, it is important to add the suicidal behaviors questionnaire revised to her assessment to identify suicidal behaviors (CSSRS revealed no risk).
• Hypothyroidism (E03.9) is caused by a underactive thyroid gland.This is the most common medical condition related to depressive symptoms.Specifically, our thyroid levels affect our mood and behaviors, energy levels and weight.G.W. denies hypothyroid symptoms of weight changes but endorses changes in mood and her behavior.Obtaining TSH and thyroid hormone levels (i.e., T3, T4) allow for either ruling out or confirming thyroid hormones are causing her mood abnormalities (i.e., depression).The thyroid hormone triiodothyronine (T3) is the most common thyroid hormone when looking into treatment or assessment of depression.Patient presentation and symptoms that are similar to symptoms of hypothyroidism are fatigue, forgetfulness, mood swings, short temper and sleep difficulties.The more severe the thyroid disease, the more severe our patient’s mood swings and temper will be.

1. General anxiety disorder (f41.1)- Generalized anxiety disorder, also known as ‘social anxiety disorder’, is characterized by a pattern of constant or frequent worry, which makes life difficult to manage and relaxation nearly impossible.Specifically, patients describe anxiety as the extreme worry that does not go away (Vijay, 2017).Patient presentation that is consistent with general anxiety disorder are chest tightness, difficulties breathing, sweating, nervousness, and changes in urinary or bowel habits.Our patient reveals she “wets the bed” occasionally, so this warrants further investigation into feelings of anxiety.Our patient denies difficulty concentrating or trouble sleeping; however, she endorses the general anxiety disorder symptoms of excessive worry and becoming stressed or upset.The worry may be considered minor, but will interfere with daily duties or impose on future plans (Vijay, 2017). For example, she reveals that she experiences excessive worry about the future, “how will I pass my classes this summer in summer school to continue”. Reports a fear of the unknown.Testing to confirm or reject this diagnosis include, laboratory testing for acetylcholinesterase (high levels reveal anxiety), CBC, CMP and electrolye imbalances.Complete physical examination and a complete personal history is essential to diagnose or rule out anxiety (i.e., Zung Self-rating anxiety scale, Hamilton anxiety scale, Beck anxiety scale). The screening question tools for generalized anxiety will aid in measuring the levels of anxiety and confirm this diagnosis.
2. Separation anxiety (f93.0-) I chose to include separation anxiety as a differential diagnosis since our patient reveals 4 months ago, she switched middle schools related to her parents not being able to afford private school and that her “best friend” moved away 5 weeks ago due to their parents getting a new job.G.W. reports struggling to cope with the loss of her friend and has not been able to make new friends, either.Triggers for separation anxiety are changes in surroundings, moving to a new home or city, switching schools, loss of relationship or death of close family member or loved one (Gonzales, & Green, 2020).Also, G.W. reports occasional nocturnal enuresis, which is consistent with symptoms of separation anxiety.To confirm this diagnosis, we must complete careful assessment and ask her questions specific to her thoughts and feelings and observe G.W.’s behavior while doing so.

1. Adverse effects of medication (T50.905A), specifically Vitamin B6-The benefits of taking vitamin B6 include healthy red blood cell production, reducing heart disease or cholesterol, promoting sleep and helping our nervous system to function correctly (i.e., maintenance or development of neurotransmitters) (Ueland, Midtun, & Gregory, 2015).Specifically, for a female G.W.’s age (12 years old), vitamin B6 is involved in the production of serotonin for mood regulation and aids in the sleep- inducing hormone of melatonin.The recommended dose of Vitamin B6 daily for female adolescents is 1.0mg (Ueland, Midtun, & Gregory, 2015).I chose to include malabsorption of the vitamin b6 and medication side effects as a potential cause for G.W.’s change in mood since our patient reveals she is taking 2mg of supplemental vitamin B6 daily. This could pose problem to how long or how much of the medication is staying in her body or being absorbed.Taking more supplemental vitamin B6 than is recommended poses threat to our patient and can causes unwanted side effects of ataxia or lack of muscle control or coordination, painful skin lesions, heartburn, nausea, or numbness (Ueland, Midtun, & Gregory, 2015).The patient denies feeling any painful skin lesions and lack of muscle control or coordination, but the patient does endorse feelings of heartburn or chest tightness.Also, G.W. denies feeling fatigue, weakness, skin lesions or pain, vitamin B6 toxicity may be ruled out. However, to confirm or reject vitamin b6 toxicity, a laboratory blood test and 24-hour urine sample test should be obtained.

Reflections:

G.W.’s presentation is consistent with that of major depressive disorder.The core features of depression are fatigue or sleep disturbance, anxiety, neurocognitive and sexual dysfunction, and loss in pleasure or interest in activities (Bains, & Abdijadid, 2021).Specifically, the loss of interest in activities will result in forgetfulness or hopelessness, and decreased feelings in self-worth.During the assessment, our patient reports she feels she “pretty much ruined everything” and feels her parents and sister “hate” her.Learning that she has been experiencing difficulties with falling or staying asleep further confirms her diagnostic criteria for depression.Also, since she has a family history of depression (depression in her mother), it is possible our patient also suffers from depression.If we can help improve her depression which is the first likely cause of her symptoms, we can then help in alleviating her anxiety symptoms.In my experiences in clinical and working at the bedside, if we can help alleviate depressive symptoms, we, in turn, help in reducing anxiety and panic symptoms at the same time.

My preceptor and I did discuss possible initiation of Zoloft for G.W.’s mood, but since her mother reported she has been on Prozac herself and finds it effective, we chose Prozac instead of the Zoloft. Prozac is first line antidepressant recommended for patients 8 years and older and has been proven to be most effective in treating adolescent depression (Gonzales & Green, 2020).Prozac 10mg daily will help with both reducing depressive and anxiety symptoms for G.W. as it is an SSRI and will work by blocking the absorption of serotonin in her brain.Regulating the amount of serotonin helps brain cells to transmit their messages to one another, which results in a more stable, better mood.In prescribing Prozac, I did educate the mother about co-morbidities that are involved with depression (i.e., substance use or abuse), but if I were to assess G.W. again, I would have focused on the risk of poor self-function and self- identity.Also, I would have discussed gene testing with the patient and her mother to assess which medications genetically would work best for G.W..Gene sight psychotropic testing will analyze how G.W.’s genes may affect medications prescribed to her.Along with antidepressants, I would encourage G.W. to partake in psychotherapy, activities to improve her overall function (i.e., exercise, developing new hobby, better sleep habits, etc.).Referring G.W. to outpatient therapy services and encouraging her to attend groups or participate in cognitive behavioral therapy will help in the reduction of her symptom and improve her overall mood.

The FDA advises that we “prescribe the smallest quantity of pills possible to help reduce the risk of deliberate or accidental overdose” (p.38). Careful monitoring by parents or guardians and health providers is important for any child taking an antidepressant because of increased suicidal thoughts during the first few months of treatment or when dosage is either increased or decreased (Gore, Chugh, & Gautam, 2017). Symptoms of self-harm or suicidal ideation are sometimes difficult to see, so it is important to educate parents about signs of worsening depression (i.e., talk of suicide or dying, suicide attempt or self-injurious behaviors, agitation, aggression, restlessness, impulsiveness, etc.) (Gore, Chugh, & Gautam, 2017). Also, it is crucial parents and guardians are aware that most adverse effects of antidepressants present and are most severe early in treatment. If I were to do this intake differently, I would have asked the patient more questions about herself injurious behaviors (i.e., why did she start cutting at a young age? Did she start cutting again because of her new school? Because her best friend moved away? Is this only home related?).

The importance of drug safety and efficacy in pediatric or adolescent population gains less attention as compared to other ages (i.e., adolescent, adult). I believe there is a need for legal obligation for pharmaceutical companies to perform trials on children if they intend to develop use in the pediatric population. Childhood illness or disease may be different than their adult equivalents so there may be more risk in therapy or treatment as compared to the benefit.

If I could re-do this evaluation, I would have asked the patient’s mother to step out of the room to assess and interview G.W. alone.G.W. revealed how she was feeling, but I do feel if her mother was not present, she may have opened up more and answered questions more in depth. I did not ask her specifically about her diet or appetite, so I would include this next time in her evaluation. Having her mother involved in her treatment is critical for improvement, but, also, asking her father or sister about G.W.’s mood would benefit her treatment, too.As providers and prescribers, it is our duty to educate our patients, as well as those family members of theirs who are involved in their care.

Case Formulation and Treatment Plan:

• Complete psychiatric evaluation and mental status exam
• Rule out medical and organic causes of psychiatric illness. Medical work up to include laboratory diagnostics as listed above
• Initiate Prozac 10mg qD for mood (depressive symptoms), Benadryl PRN HS to aid in sleep
• Education about diagnosis and treatment to patient and her mother
• Education on psychiatric illness and medications including risks, benefits and alternatives including no medication.
  • Psychoeducation including abnormal and normal behaviors
• Combine cognitive behavioral approaches for depression, anxiety and impulse control
  • Reshape negative thoughts to positive
  • Incorporate positive affirmations
  • Keep schedule for routine
  • Begin journal/diary for mood and behaviors, explain how she feels from day to day
  • Begin new hobby or learn something new
• Compare effects of treatment with medications versus interpersonal or psychodynamic therapy
• Assess rating scales once patient completes and review with patient
  • Tailor needs with rating scales
• Evaluate suicidality/ homicidally/ lethality and substance use treatment needs
• Provided patient with crisis telephone numbers and the community’s suicidal hotline
  • Discussed with patient self-injurious behaviors, suicidal ideations/passive and active
  • Encouraged to seek emergency care or ER again if she becomes suicidal or homicidal
• Patient encouraged to attend therapy and counseling services—provided with information about individual and group therapy sessions/cbt
  • Provided patient with resources for grief counseling related to death and loss
• Allotted time to discuss and voice concerns – patient encouraged to keep journal or diary about her feelings and moods to observe if there is specific/new trigger
• Follow up therapy session scheduled for 5 weeks.

Discussion questions:

• How does patient presentation of depression differ amongst pediatric, or adolescent compared to adult/ geriatrics? How are they similar?
• Have you ever treated a patient suffering from both depression and anxiety/ panic symptoms? How do the symptoms overlap?
• When treating patients with multiple mental illnesses, do you feel they may overplay or downplay their symptoms?Do they lack insight or judgement into their illness? Or are they aware?
• For patients struggling with multiple mental illnesses, how do you think we can help in easing their symptoms? Do you favor psychotherapy over medications? Or vis versa?