Reply Candace

What would the focused clinical assessment include?

This writer’s clinical assessment would be focused on symptoms of depression. The history is key in diagnosing. Feeling depressed can be a normal reaction to loss, life’s struggles or an injured self-esteem. Patients should be asked questions that leads to them expressing symptoms such as complaints of feeling fatigued, irritability, and social withdrawal. Assessment of the patient hygiene and mood should be completed. These patients normally have a flat affect and poorly dressed. There are two questions that provide a preliminary screen for depression. The patient is first asked if he or she has felt down or hopeless over the past month and then asked if there has been little interest in doing things over the past month (Dunphy, Winland-Brown, Porter, & Thomas, 2015).

What are the differential diagnoses?

A careful history and physical must be done due to the many medical and neurological disorders and pharmacological substances can produce depression symptoms. Neurological disorders such as Parkinson’s which accounts for 50%-70% of depressive symptoms, Dementia, Multiple Sclerosis, and cerebrovascular accident (CVA). Endocrine disorders such as hypo and hyperthyroidism and mental disorders such as schizophrenia and eating disorders are amongst those displaying depressive symptoms. There also can be drug related issues such as cocaine abuse and central nervous system (CNS) depressants.

What major psychological question needs to be addressed?

There are many different test that can be given to determine whether a patient has depression or a differential diagnosis. A major question that can be asked, “In the past two weeks how often have you felt down, depressed or hopeless?”  Feeling down for more than half the days or nearly every day over the past two weeks suggests depression (Lliades, 2016).

What testing should be ordered to rule out medical problems?

Test can be done to rule out other medical conditions that might cause depression symptoms. Testing of the thyroid and adrenal function can be done. Assessment of patient medication to rule out substance abuse is also done. The most important test is called the DSM-5. This test states that if five of the symptoms that are listed on the criteria and are present for 2 weeks then the patient can be diagnosed with depression.

Plan of Care

The plan of care for the patient includes remission of symptoms. Remission is defined as an absence of depressive symptoms or a PHQ-9 score of less than 5, and this is the goal of therapy. Treatment will also begin with pharmacological and nonpharmacological interventions. A referral to a therapist can also be ordered to help the patient get through the depression.

Mainstay of Treatment

Treatment consist of the selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), norepinephrine reuptake inhibitors (NRIs), tricyclic antidepressants (TCAs), and dopamine agonists (DAs) are the first line of treatment. Non-pharmacological treatment include behavioral therapy with combination of psychotherapy can also be beneficial to the patient.

Follow Up Plan

Follow up treatment is necessary to assess adherence to therapy. The patient at 6 weeks should experience a 25% reduction in baseline symptom severity. Initially the patient should be seen one to two weeks after initiation of medication therapy than once in the succeeding four to eight weeks. If patients remain symptom free patients can be treated for 15 months to five years.

Patient Education

It is important that practitioner teach the patient to report the symptoms such as irritability, agitation and suicidal ideation. Emergency hotline numbers should be given in case the patient symptoms emerge. Patient and family should be educated regarding the signs and symptoms and also what to do in this case.

References

Dunphy, L., Brown, J., Porter, B., & Thomas, D. (2015). Primary Care: The Art and

Science of Advanced Practice Nursing. Philadelphia: F.A. Davis Company

Lliades, C. (2016). 5 Questions Doctors Ask When Screening for Depression. Retrieved

from www.everyda (Links to an external site.)Links to an external site.yhealth.com

Reply Amanda

1. What would your focused clinical assessment include?

I would assess this patient’s mood, hygiene, appearance, affect and thought process. I would conduct a mini cognitive exam to rule out evidence of dementia. I would also complete a mini-mental-status exam (MMSE) to assess this patient’s cognitive function.

1. What are your initial differential diagnoses?

Hypothyroid, depression, anxiety, dementia, and insomnia.

1. What major psychological question needs to be addressed?

Do you want to harm yourself or others?

If you want to harm yourself, do you have a plan?

How would you do it?

1. What testing would you order to rule out any medical problems?

CBC, CMP, and TSH

1. What is your plan of care?

For this patient I would obtain routine lab work to rule out any medical conditions. Discuss appropriate coping mechanisms for stress, anxiety, and depression. Encourage routine exercise, healthy diet, and sleep hygiene. “Exercise is an efficacious treatment approach for the prevention and management of depression”

1. What are the mainstays of treatment? What is your initial follow up plan?

Although many providers would begin a TCA, SNRI, or SSRI – I would be hesitant to do so in this case. I would feel more comfortable obtaining baseline labs, encouraging lifestyle modifications, and a follow up appointment. These popular pharmacologic interventions are not without side effects and may impose long term implications for patients.  The treatment of depression/anxiety/insomnia isn’t always as easy as a pill. I would have the patient return to clinic in 2 weeks to review lab work and discuss the effectiveness of cited lifestyle changes.

1. What education would you provide to your patient?

I would educate this patient regarding needing lifestyle changes as well as the plan of care. I would inform her that if lifestyle modifications provide no change in symptoms there are pharmacological options. The treatment of depression, anxiety, and insomnia is multifaceted and may include nonpharmacological and pharmacological interventions (Sarris, 2011).

References 

Farris, S. G., Abrantes, A. M., Uebelacker, L. A., Weinstock, L. M., & Battle, C. L. (2019). Exercise as a nonpharmacological treatment for depression. Psychiatric Annals, 49(1), 6-10. doi:http://dx.doi.org/10.3928/00485713-20181204-01

Sarris, J. (2011). Clinical depression: An evidence-based integrative complementary medicine treatment model. Alternative Therapies in Health and Medicine, 17(4), 26-37. Retrieved from https://prx-herzing.lirn.net/login?url=https://search.proquest.com/docview/940001626?accountid=167104