What additional information would you want to know in the history to further assess this patient's level of safety and suicide risk??What recommendations would you mak

Week (4): COMPLEX CASE STUDY PRESENTATION

Nanati, Birassa

College of Nursing-PMHNP, Walden University

PRAC 6675: PMHNP Care Across the Lifespan I

Walden Universtiy

12/18/23

Subjective:

CC (chief complaint):” I feel so bored. I’m not interested in anything anymore.”

HPI: The patient is a 15-year-old Caucasian female who presents with her mother for psychiatric follow-up. The patient reports persistent depressed mood most days over the past three months, described as “feeling sad all the time.” She endorses crying spells 2-3 times per week, irritability, low frustration tolerance, isolation from friends, loss of interest in usual activities like dance class and shopping, difficulty concentrating resulting in lower quiz grades, low motivation (hard to get out of bed for school), fatigue, mild weight gain, and intermittent passive suicidal ideation including thinking “I wish I wouldn’t wake up” but denies plan. Symptoms began gradually earlier this year in the context of parental conflict over divorce but have persisted despite the family entering counseling two months ago. Symptoms are now severely impacting her ability to function at school, with three missed days each week over the past month and a drop in science class grade from a B+ to a C-. The patient also resigned from the dance team in the past month due to a lack of interest and energy. The patient continues to deteriorate in performance despite advisor and teacher interventions. The mother notes severely impaired mood and new oppositional behaviors.

Substance Current Use: Denies use of alcohol or illicit substances.

Medical History:

· Current Medications: None.

· Allergies: NKDA

· Reproductive Hx: Menarche at age 13. No sexual activity, not in a relashionship .

ROS:

· GENERAL: Slight weight gain within the last few months. Denies fever, chills, weakness or fatigue beyond symptoms of depression.

· HEENT: Eyes: No visual changes. Denies eye pain, double vision. Ears: No decrease in hearing or tinnitus. Nose/Throat: No congestion, runny nose, sore throat.

· SKIN: No reported rashes or skin changes. Non-pruritic.

· CARDIOVASCULAR: Negative for chest pain, pressure or discomfort. No edema, varicose veins. Normal pulses.

· RESPIRATORY: Breathing is normal, no cough or shortness of breath.

· GASTROINTESTINAL: Appetite decreased secondary to depression. No nausea, vomiting, diarrhea. No abdominal pain. Bowel movements normal.

· GENITOURINARY: Last menstrual period 2 weeks ago, normal flow. Negative for painful/irregular periods. Negative for frequent/painful urination.

· NEUROLOGICAL: No headaches, dizziness, syncope, seizure activity. No numbness or tingling. Normal coordination and gait.

· MUSCULOSKELETAL: No muscle weakness or joint pains. Full range of motion.

· HEMATOLOGIC: Negative for easy bleeding or bruising.

· LYMPHATICS: No enlarged nodes. Thyroid normal size.

· ENDOCRINOLOGIC: No temperature intolerance, polyuria, polydipsia to suggest endocrine dysfunction. Negative for symptoms of thyroid disorder.

Objective:

Diagnostic results: The patient visited her primary physician five days ago and brought her lab results on this visit. Labs, including CBC and CMP, are within normal limits. Thyroid studies WNL. Urine drug screen negative.

Assessment:

Mental Status Examination: The patient is a 15-year-old female who appears slightly younger than her stated age. She presents as tired-looking but pleasant and cooperative. Speech is slow and soft. The mood is depressed and anxious. Affect is constricted but congruent with mood. She cries several times when discussing her symptoms. The thought process is linear and goal-directed. She admits to suicidal ideation but has no intent to act on it; however, she denies having homicidal ideation. Cognition is grossly intact based on the interview. Insight and judgment are good.

Diagnostic Impression: 

1. Major depressive disorder, recurrent, moderate, without psychotic features. The patient’s symptoms   meet the criteria, including depressed mood, diminished interest and pleasure in activities, weight gain, fatigue, impaired concentration, indecisiveness, and passive suicidal ideation. Symptoms cause significant distress and impairment across domains of functioning.

2. Generalized anxiety disorder:  Endorses excessive anxiety and worry about a variety of topics, including school performance, family conflict, and the health of parents, for over two months: associated restlessness, concentration difficulties, irritability, muscle tension, and sleep disturbance. The patient’s symptoms do not meet the criteria for a primary diagnosis of anxiety disorder because the symptoms have not lasted for at least six months. 

3. Persistent depressive disorder (dysthymia):  Endorses overeating, hyper insomnia, poor concentration, and low energy. However, the patient does not meet the criteria for chronically depressed mood >2 years, given the onset of symptoms two months in the specific context of parental conflict and upcoming divorce. I will continue to monitor the course over time. 

Reflections: This is a case of a 15-year-old adolescent female presenting with apparent symptoms meeting DSM-5 criteria for major depressive disorder, recurrent episodes, and moderate severity. She endorses core symptoms, including nearly daily depressed mood, diminished interest and pleasure in activities, fatigue, feelings of worthlessness and passive suicidal ideation, sleep and appetite changes with associated weight gain, and concentration problems leading to academic decline. Of note, symptoms began in the context of parental conflict but have persisted and worsened for three months despite the family now entering counseling, indicating this is not merely an adjustment reaction.

Given the duration and severity of impairment meeting the criteria for MDD, I agree with the preceptor’s assessment and plan to start an SSRI antidepressant and CBT. However, careful monitoring for increased suicidality will be crucial given the patient’s young age, passive SI at baseline, and family history of possible bipolar disorder. I would also ensure close collaboration with the school counselor to communicate treatment modifications and assess the need for 504 accommodations if depression continues impairing academics. Ongoing monitoring for the emergence of mania or psychosis will be equally crucial given the family history, though less likely with unipolar MDD onset.

Regarding psychosocial factors, clearly, the parental conflict and ensuing divorce is an initial precipitant we must address in counseling by assessing the patient’s coping skills and perspective on the situation at home. We should also evaluate social support from peers at school or the church community where she recently resigned from dance. Promoting engagement in rewarding activities will be just as crucial as managing unhealthy thoughts. As this is an adolescent female already at higher risk for trauma and self-harm, meticulously assessing suicidality and means safety at each visit is vital. However, she currently has good judgment and insight.

Overall, I agree with the patient meeting the criteria for MDD and the treatment plan to target both medication and psychosocial levels of intervention through an SSRI and CBT. Care coordination with the school and monitoring for suicidality/mania will optimize the likelihood of positive outcomes. I would not change my agreement with the assessment or plan at this time, but I will adapt interventions based on her symptoms and functional response in follow-up visits. Ongoing re-evaluation for alternative diagnoses will remain essential.

Case Formulation and Treatment Plan: 

The patient will be started on Prozac 20mg daily. Will monitor for increased SI, irritability, allergy, or increased anxiety and suicidal thoughts. The patient and mother understand the risks of medication and instructions for safety monitoring and reporting adverse reactions. The mother agrees to monitor drugs and symptoms.

The patient is referred to a counselor for CBT and supportive therapy. Appointments will begin biweekly, focusing on coping skills, problem-solving, and addressing unhealthy thoughts.

The mother and patient have been instructed to remove any firearms from home while the patient is symptomatic- safety planning. Neither endorses the availability of weapons in the house. Reviewed and updated safety plan – Patient to call emergency services and mom if significant worsening of mood, emergence of SI, or uncontrolled anger outbursts. She will continue sessions with the school counselor for support. There will be a follow-up in 2 weeks for a medical check-up. The mother and patient verbalize understanding of the safety plan.

PRECEPTOR VERFICIATION:

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

Bahji, A., Pierce, M., Wong, J., Roberge, J. N., Ortega, I., & Patten, S. (2021). Comparative efficacy and acceptability of psychotherapies for self-harm and suicidal behavior among children and adolescents: a systematic review and network meta-analysis.  JAMA network open,  4(4), e216614-e216614.

Bains, N., & Abdijadid, S. (2020). Major depressive disorder.

Chavez, B., Sullivan, J., & Portela, P. (2023). Improving Adolescent Depression in Primary Care: A Quality Improvement Initiative.  The Journal for Nurse Practitioners,  19(3), 104503.

Mangione, C. M., Barry, M. J., Nicholson, W. K., Cabana, M., Coker, T. R., Davidson, K. W., … & US Preventive Services Task Force. (2022). Screening for anxiety in children and adolescents: US Preventive Services Task Force recommendation statement.  JAMA,  328(14), 1438-1444.

Pacchiarotti, I., Kotzalidis, G. D., Murru, A., Mazzarini, L., Rapinesi, C., Valentí, M., … & Verdolini, N. (2020). Mixed features in depression: the unmet needs of diagnostic and statistical manual of mental disorders fifth edition.  Psychiatric Clinics,  43(1), 59-68.

Discussion prompts

1. What additional information would you want to know in the history to further assess this patient’s level of safety and suicide risk?

2. What recommendations would you make regarding school accommodations or 504 plan eligibility given this patient’s major depressive episode is impairing multiple areas of academic functioning? As her treatment team, how would you engage with school counselors or administration on needed supports?

3. This patient has a family history of possible bipolar disorder. What early warning signs of manic switch or mood cycling would you monitor for in follow-up visits to rule out bipolar presentations?

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