This is a case presentation of a 44-year-old Black male who presented to the office for a psychiatric evaluation
This is a case presentation of a 44-year-old Black male who presented to the office for a psychiatric evaluation. The patient was referred by his PCP for worsening depressive symptoms.
Objectives:
To perform a complete psychiatric assessment.
To help patients improve their quality of life in dealing with depression
To help the patient improve his mood by reducing his depressive symptoms.
Subjective:
CC (chief complaint): “ I am feeling depressed, and I need help for my depression.”
HPI: G.G. is a 44-year-old- Black male who presented to the office for a psychiatric evaluation for worsening depression. He was taking Lexapro 5mg, which he complained of because the medication causes erectile dysfunction, and Remeron 15mg, with complaints of increasing nightmares, and he stopped taking them. The onset of his symptoms started two years ago after witnessing his younger brother get shot and killed during a robbery at a gas station. His relocation to Miami has also contributed to his depression. Since then, he has become depressed. He reported the following symptoms: feeling guilty, helpless, sad, and anxious. He reportedly feels constantly depressed that he has no drive to work, no energy, and no appetite. He has difficulty falling or staying asleep because of bad dreams, palpitations, and nightmares about the incident. He mentioned trouble focusing at work, and he gets angry outbursts at home and work. He also mentioned losing interest in things that he once enjoyed.
Past Psychiatric History: The patient’s depressive symptoms started two years ago and worsened six months ago, which reminded him of his brother’s anniversary.
Caregivers: He lives with his wife and three children.
Hospitalizations: He has never been hospitalized.
Psychotherapy or Previous Psychiatric Diagnosis: The patient has never attended psychotherapy but had seen a psychiatrist two years ago and was diagnosed with depression and PTSD.
Substance Current Use: The patient drinks alcohol and smokes cigarettes.
Family Psychiatric /Substance Use History: His father has a history of alcohol and depression. His younger brother had depression.
Psychosocial history: G.G. relocated to Miami, Florida, from Detroit, Michigan, two years ago with his wife and three kids. His single mother raised him, and he completed high school. He works at a supermarket as a security guard. He likes spending time with his family and going to church. He was arrested at 16 for a misdemeanor.
Medical History:
Current Medications: Metoprolol 25mg daily for high blood pressure. Simvastatin 10mg at bedtime for hyperlipidemia.
Allergies: NKA
Reproductive Hx: G.G. has three children: two girls, ages 20 and 17, and a son who is 14 years old.
ROS:
GENERAL: The patient appears to be of the stated age. He Denies any fevers, sweats, or chills. He reports feeling fatigued and lost seven pounds.
HEENT: His head is normocephalic. He wears glasses. He has no double vision, discharge from his eyes, itching, nosebleeds, or ringing of the ears. He denies headache, sinus pain, or pressure and has no sore throat.
SKIN: His skin was dry, with no rashes, itching, or lesions.
CARDIOVASCULAR: No chest pain or shortness of breath. He reported palpitations.
RESPIRATORY: No coughing, wheezing, or phlegm. No history of asthma.
GASTROINTESTINAL: No digestive system or abdominal discomfort was reported.
GENITOURINARY: No dysuria, hematuria, or urinary incontinence. No history of UTI or STDs.
NEUROLOGICAL: Denies numbness and tingling in hands and feet. There is no history of seizures.
MUSCULOSKELETAL: G.G. complains of fatigue. Denies muscle or back pain
HEMATOLOGIC: Denies anemia or bleeding problems. No bruising or splenectomy.
LYMPHATICS: No swollen lymph nodes.
ENDOCRINOLOGIC: G.G. has lost seven pounds. No polyurea, polydipsia, high glucose levels, or cold/heat intolerance was reported.
This is a case presentation of a 44-year-old Black male who presented to the office for a psychiatric evaluation
Objective:
Diagnostic results: The patient’s Health Questionnaire-9 (PHQ-9) score is 15/27, which indicates moderate depression. The Depression Inventory (BDI) score is 15 (moderate) for depression. Generalized Anxiety Disorder-7 (GAD-7) score is 2. CBC, CMP, and UA were within normal limits.
Assessment:
Mental Status Examination: G.G. is a 44-year-old black male who is alert and oriented x3. He appears well-groomed and dressed appropriately for the weather. His speech is coherent with moderate tone and volume. His thought process was logical and goal-directed.
His insight and judgment were fair. During the interview, he maintained minimal eye contact. He appeared sad, labile, and depressed mood with a flat affect. No signs of abnormal activities were noted. He denied suicidal or homicidal ideations.
Diagnostic Impression:
Major Depressive Disorder is a mental health condition that is described as a constant depressed mood, sadness, decreased energy, and decreased interest in pleasurable activity. The patient also complained of feeling guilty, lack of energy, poor concentration, changes in appetite, and sleep disturbances. Researchers believe that depression is due to a chemical imbalance in the brain between the neurotransmitters dopamine, serotonin, and norepinephrine. Genetic, biological, environmental, and physiological factors also play a role in developing this condition (Li et al., 2021). Using the DSM-5, the criteria for diagnosing major depression, the person must present with at least five of the symptoms, including low energy, concentration, decreased sleep and appetite, and no interest in life (American Psychiatric Association, 2022). G.G. perfectly fits the diagnosis of depression because he presented with the classic signs and symptoms mentioned above.
Post-traumatic stress disorder is a mental health condition that occurs after witnessing a traumatic event. Signs and symptoms include having flashbacks of the event, nightmares, trouble sleeping and concentrating, feeling guilty, angry outbursts, and lack of interest in activities once enjoyed. These symptoms cause significant social and relationship problems (Lancaster et al., 2016). The criteria for PTSD is that the individual must be directly affected by the traumatic event and must experience the following symptoms such as feeling guilt or shame, diminished interest in significant activities, Inability to experience joy, difficulty concentrating, and angry outbursts. These symptoms must be present longer than one month and interfere with daily life (American Psychiatric Association, 2022).
Generalized Anxiety disorder is when a person is apprehensive about everyday life events for no apparent reason. People with generalized anxiety experience the following signs and symptoms, including difficulty concentrating, fatigue, trouble falling or staying asleep, and heart palpitations (Gkintoni & Ortiz, 2023). According to the DSM-5, for a diagnosis of generalized anxiety, the individual must exhibit persistent fear and worry every day for at least six months with the symptoms mentioned above (American Psychiatric Association, 2022).
Reflections: The patient presented with clinical signs and symptoms of depression, PTSD, and anxiety. A complete psychiatric and medical history, physical exam, and a review of current prescription and over-the-counter medications. Also, mental status examination and laboratory work, including complete blood count with the differential, comprehensive metabolic panel, thyroid-stimulating hormone, free T4, vitamin, urine drug screen, blood alcohol level, and C.T. scan (McKee & Brahm, 2016). The findings will give the provider good insight into the patient’s health and help to diagnose and treat the condition properly.
The patient presented with clinical signs and symptoms of depression, PTSD, and anxiety. A complete psychiatric and medical history, physical exam, and a review of current prescription and over-the-counter medications. Also, mental status examination and laboratory work, including complete blood count with the differential, comprehensive metabolic panel, thyroid-stimulating hormone, free T4, vitamin, urine drug screen, blood alcohol level, and C.T. scan (McKee & Brahm, 2016). The findings will give the provider good insight into the patient’s health and help to diagnose and treat the condition properly. I would ensure to incorporate thyroid function testing because hypothyroidism is one of the medical conditions that can imitate the signs and symptoms of depression. Patient involvement, culture, race, and religion are essential for patient care. They will guide the provider in better understanding the patient and developing the right treatment plan tailored to them. The Provider must provide informed consent and explain the risks and benefits of the treatment. The patient must agree with the plan. In addition, as far as determinants of health, the provider must assess G.G.’s household income and the neighborhood in which he lives. The provider must determine if he can pay his bills and afford his medications; given that G.G. is the sole breadwinner, he might need assistance with housing and food stamps. The patient’s social determinant of health can affect the patient’s response to treatment.
Case Formulation and Treatment Plan: The treatment plan for G.G.’s would include psychotherapy and psychopharmacological interventions. Cognitive behavioral therapy works by modifying maladaptive thoughts and behaviors into positive patterns of thinking and behaving (Nakao et al., 2021). The therapist will teach G.G. a new coping mechanism to manage depression, nightmares, flashbacks, and anxiety. The pharmacological intervention will include Wellbutrin (Bupropion) SR 100mg for depression and anxiety and Prazosin 1 mg for flashbacks and nightmares. The most common side effects include headache, weight loss, dry mouth, insomnia, nausea, dizziness, constipation, and palpitations (Reyes & Figueroa, 2020). The most common side effect of prazosin is orthostatic hypotension (Richardson et al., 2022). In addition, relaxation techniques, such as deep breathing exercises, can help with depression, PTSD, and anxiety.
Patient Education: The patient will be educated about the medication’s side effects, such as headache, weight loss, dry mouth, insomnia, nausea, vomiting, dizziness, constipation, palpitation, and hypotension. The patient will be advised to get up slowly and lie down to reduce caffeine intake and increase fluid intake. The patient will also be educated about medication compliance and not to stop the medication abruptly without consulting the provider. The patient is also advised to report any side effects or adverse effects of the medicines. The patient is educated about the risks of OTC drugs, herbal, alcohol, and illegal while taking antipsychotic drugs and to avoid this practice.
Additionally, the patient is advised to report any suicidal or homicidal ideations and to call 911 for any emergency. The patient is scheduled for a two-week follow-up to monitor side effects, medication response, and treatment plan. The patient verbalized understanding and agreed with the plan.
Questions to classmate
How does culture contribute to depression?
Is the patient’s gender a determining factor in seeking help for depression?
What role does family play in depression?
I confirm the patient used for this assignment is a patient that was seen and managed by the student at their Meditrek approved clinical site during this quarter course of learning.
Preceptor signature: ________________________________________________________
Date: ________________________
References
American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed.). American Psychiatric Association. https://doi.org/10.1176/appi.books9780890425787.x03
Gkintoni, E., & Ortiz, P. S. (2023). Neuropsychology of generalized anxiety disorder in clinical setting: A systematic evaluation. Multidiciplinary Digital Publishing Institute, 11(2446). Retrieved March 19, 2024, from https://doi.org/10.3390/healthcare11172446
Lancaster, C. L., Teeters, J. B., Gros, D. F., & Back, S. E. (2016). Posttraumatic stress disorder: Overview of evidence-based assessment and treatment. Multidisciplinary Digital Publishing Institute. Retrieved March 19, 2024, from https://doi.org/10.3390/jcm5110105
Li, Z., Ruan, M., Chen, J., & Fang, Y. (2021). Major depressive disorder: Advances in neuroscience research and translation applications, 37(6), 863–880. Retrieved March 19, 2024, from https://doi.org/10.1007/s12264-021-00638-3
McKee, J., & Brahm, N. (2016). Medical mimics: Differential diagnostic considerations for psychiatric symptoms. Mental Health Clinician. Retrieved March 19, 2024, from https://doi.org/10.9740/mhc.2016.11.289.
Nakao, M., Shirotsuki, K., & Sugaya, N. (2021). Cognitive-behavioral therapy for management of mental health and stress-related disorders: Recent advances in techniques and technologies. BiopsychoSocial Medicine, 15(16). Retrieved March 19, 2024, from https://doi.org/10.1186/s13030-021-00219-w
Reyes, R., & Figueroa, S. (2020). Bupropion overdose as a clinically significant confounder of the neurological examination. Journal of Neurocritical Care, 13(2), 109–114. Retrieved March 19, 2024, from https://doi.org/10.18700/jnc.200021
Richardson, C., Swartz, A., & Forsberg, M. (2022). Prazosin dosed 3 times a day to treat flasbacks related to ptsd: A case report. Mental Health Clinician. Retrieved March 19, 2024, from https://doi.org/10.9740/mhc.2022.08.267
Sun, Y., Fu, Z., Bo, Q., Mao, Z., Ma, X., & Wang, C. (2020). The reliability and validity of PHQ-9 in patients with major depressive disorder in psychiatric hospital. BioMed Central Psychiatry, 20(474). Retrieved March 19, 2024, from https://doi.org/10.1186/s12888.020-02885-6
This is a case presentation of a 44-year-old Black male who presented to the office for a psychiatric evaluation
**Objective of Presentation:**
To conduct a comprehensive psychiatric assessment of a patient presenting with depression and anxiety.
To develop a treatment plan aimed at improving the patient’s mood and quality of life.
To explore the impact of social determinants of health on the patient’s mental health status and treatment outcomes.
**Discussion Questions/Prompts:**
How do cultural factors influence the manifestation and treatment of depression in diverse populations?
What are some barriers to seeking help for depression based on gender roles and societal expectations?
How does family support or lack thereof contribute to the development and management of depression?
**Complex Case Study:**
**Subjective:**
The patient, G.G., a 44-year-old Black male, presents with worsening depression following the traumatic loss of his younger brother two years ago and subsequent relocation to Miami. He reports feelings of guilt, sadness, anxiety, and loss of interest in activities. Additionally, he experiences nightmares, anger outbursts, and difficulty concentrating.
**Objective:**
Upon examination, G.G. appears well-groomed and coherent but exhibits a sad mood with minimal eye contact. He denies suicidal ideation. Diagnostic results indicate moderate depression based on PHQ-9 and BDI scores, with no significant anxiety symptoms according to the GAD-7 scale. Laboratory tests are within normal limits.
**Assessment:**
Differential diagnoses include Major Depressive Disorder (MDD), Post-Traumatic Stress Disorder (PTSD), and Generalized Anxiety Disorder (GAD). G.G. meets criteria for MDD due to persistent depressed mood, anhedonia, and impaired concentration, as well as PTSD characterized by flashbacks, nightmares, and anger outbursts.
**Plan:**
Treatment plan includes psychotherapy and pharmacological interventions. Cognitive Behavioral Therapy (CBT) will address maladaptive thought patterns and behaviors associated with depression and PTSD. Pharmacotherapy will consist of Wellbutrin for depression and anxiety, and Prazosin for nightmares and flashbacks.
**Patient Education:**
G.G. will be educated about potential side effects of medications and advised on gradual dose adjustments and adherence. He will also receive guidance on lifestyle modifications, including relaxation techniques and avoiding alcohol and OTC drugs.
**Social Determinants of Health:**
Assessment of G.G.’s social determinants reveals potential financial strain and housing instability, which may impact treatment adherence and outcomes. Referral to community resources for financial assistance and housing support is recommended.
**Reflections:**
In hindsight, I would ensure thorough exploration of cultural and familial influences on G.G.’s condition, as well as further assessment of his social support system. Follow-up would involve monitoring treatment response and addressing any emerging barriers to care. Addressing social determinants of health is crucial for optimizing treatment outcomes.
**Case Formulation and Treatment Plan:**
The treatment plan incorporates psychotherapy, pharmacotherapy, and patient education to address G.G.’s depression, PTSD, and anxiety symptoms. Collaboration with community resources will be essential in addressing social determinants impacting G.G.’s mental health status.
**References:**
– American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed.).
– Gkintoni, E., & Ortiz, P. S. (2023). Neuropsychology of generalized anxiety disorder in clinical setting: A systematic evaluation.
– Lancaster, C. L., Teeters, J. B., Gros, D. F., & Back, S. E. (2016). Posttraumatic stress disorder: Overview of evidence-based assessment and treatment.
– Li, Z., Ruan, M., Chen, J., & Fang, Y. (2021). Major depressive disorder: Advances in neuroscience research and translation applications.
– McKee, J., & Brahm, N. (2016). Medical mimics: Differential diagnostic considerations for psychiatric symptoms.
– Nakao, M., Shirotsuki, K., & Sugaya, N. (2021). Cognitive-behavioral therapy for management of mental health and stress-related disorders: Recent advances in techniques and technologies.
– Reyes, R., & Figueroa, S. (2020). Bupropion overdose as a clinically significant confounder of the neurological examination.
– Richardson, C., Swartz, A., & Forsberg, M. (2022). Prazosin dosed 3 times a day to treat flasbacks related to ptsd: A case report.
– Sun, Y., Fu, Z., Bo, Q., Mao, Z., Ma, X., & Wang, C. (2020). The reliability and validity of PHQ-9 in patients with major depressive disorder in psychiatric hospital.
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