NSG 6330 Week 2 Discussion iHuman Case Study – Angela Cortez

Week 10 post iHuman Questions

Associated Sx/Sx Characteristics:

• How are your grades in school?
• Do you blame yourself for everything wrong?
• Have you had any thoughts of hurting or killing yourself?
• Have you been nervous, anxious or worried about something?
• Is it possible that you are pregnant?
• Are you crying more than usual?
• Do you wish you were not alive anymore or fell asleep and didn’t wake up? If so, how often have you had these thoughts?

Risk Factors:

PMH:

• Any new or recent change in medications?

SH:

• Tell me about your diet, what you normally eat.
• Tell me about daily exercise or sports that you play.
• Has drinking alcohol ever caused you problems?
• Has anyone suggested that you should reduce the amount of alcohol you drink?
• Do you feel guilty about the amount of alcohol you drink?
• Are there any guns in your home? If so, are they stored in a secure location?

Etiology:

• Are you taking any over-the-counter or herbal medications?
• How is your appetite? Any recent change?
• NSG 6330 Week 2 Discussion iHuman Case Study – Angela Cortez assignment help

HPI/ROS:

• Do you have any problems with: itchy scalp, skin changes, moles, thinning hair, brittle nails?
• Do you have any problems with: headaches that don’t go away with aspirin or Tylenol (acetaminophen), double or blurred vision, difficulty with night vision, problems hearing, ear pain, sinus problems, chronic sore throats, difficulty swallowing?
• Have you noticed: any discharge from your breast, lumps, scaly nipples, pain or swelling, redness?
• Do you experience: chest pain, discomfort, pressure, pain/pressure/dizziness with exertion or getting angry, palpitations, decreased exercise tolerance, blue/cold fingers and toes?
• Do you experience: shortness of breath, wheezing, difficulty catching your breath, chronic cough, sputum production?
• Do you have problems with: nausea, vomiting, constipation, diarrhea, coffee grounds in your vomit, dark tarry stool, bright red blood in your bowel movements, early satiety, bloating?
• Have you noticed: any bruising, bleeding gums or other sites of increased bleeding?
• Do you have any of the following: dizziness, fainting, spinning room, seizures, weakness, numbness, tingling, tremor?
• When you urinate, have you noticed: pain, difficulty starting or stopping, dribbling, incontinence, urgency during day or night. Any changes in frequency? Any blood in your urine?

Skin, no sign of self- harm, ( no cutting, picking, and cutting, burning )

Mild, comedonal acne, acanthosis nigricans at nape of neck

Striae noted on abdomen and buttocks.

Eyes are teary

Abdomen- Tanner V pubic hair distribution, scatter abdominal striae

Noted.  Bowel sounds are normal. Abdomen is soft, and nontender.

Decreased energy / interest in pleasurable activities (anhedonia)	MSAP
Fatigue	Related
Irritability	Related
25+ lb weight gain	Related
Crying more than usual	Related
Recent decline in school grades	Related
Mild to moderate obesity/elevated BMI	Related
Acanthosis nigricans	Unknown
Acne	Unknown
Striae	Unknown
Family history of obesity, DM, and HTN	Unknown

The medical key findings list, or list of pertinent findings you have compiled, should include everything that is out of the ordinary about this patient, even when it is not a “problem” in the true sense of the word.

The key findings list allows you to begin to see the overall or unified constellation of significant signs and symptoms. It is also the starting point for developing, and then ranking, your diagnostic hypotheses. The pertinent presence or absence of other critical signs and symptoms will aid your assessment of the severity of the presenting complaint and your assessment of potential comorbidities.

Angela’s main reason for her visit today and most significant active problem (MSAP) is her anhedonia or loss of interest and decreased energy for activities that used to give her pleasure. Her fatigue, irritability and daily episodes of crying could be related factors contributing to her anhedonia. Angela also states that she has had difficulty concentrating at school. Her decline in her school grades could be a result of all of the chronic issues listed above.

Because Angela has had fatigue, her decreased level of activity could contribute to her weight gain and obesity.

The physical exam findings of acanthosis nigracans, acne and striae are important to note, but at this point, we are unsure if they are related to the most significant active problem.

Her family history of obesity, DM and HTN is also important to note as this will guide our differential and testing. However, we are unsure at this point if it is related to the most significant active problem.

Next Step: Write Problem Statement

• Describe the evaluation tool and explain why this tool is essential in the care of the adolescent patient population.
• Apply the findings of the scholarly research articles to the use of this evaluation tool and describe its validity and reliability.
• Apply this evaluation tool to a patient situation and summarize your opinion of the results.
• Describe a plan of care for the patient, depending upon the results.

16yo white female present with c/o anhedonia and decrease energy. She has been experiencing fatigue, irritability and daily episodes of crying could be related factors contributing to her anhedonia. Angela also states that she has had difficulty concentrating at school. Her decline in her school grades could be a result of all of the chronic issues listed above. Pt. is feeling hopeless about weight and acne,

Angela Cortez is a 17-year-old female who presents with a history of fatigue and lack of energy for the past two months; associated with irritability and weight gain. Her symptoms have led to a decline in her school performance and lack of participation in her usual activities. She has been crying on a near daily basis over the past month. On physical exam, she has an elevated BMI, is tearful, and is noted to have acne, striae, and acanthosis. She denies any active suicidal thoughts.

Problem categories are:

Psychologic – irritable, and crying daily for months

Endocrine- fatigue, emotional lability and weight gain.

Hemotologic- fatigue

Integumentary- striae, acanthosis nigracans, and acne

Differential diagnoses

Low self esteem- R45.81

Other depressive episodes- F33.8

Chronic fatigue, unspecified- R53.82

Infectious mononucleosis, unspecified – B27.9

Pregnancy- Z34.00 Encounter for supervision of normal first pregnancy, unspecified trimester

Crushing’s syndrome is a differential diagnosis should be included because:

The common signs and symptoms of Cushing syndrome include the following:

• Weight gain particularly around the midsection of upper back, face, and between should.
• Striae
• Headache, irritability, chronic feeling of fatigue
• Hypothyroidism
• Depression

The leading diagnosis is depressive disorder, given the patient’s fatigue, anhedonia, withdrawal from social interaction , decreased ability to concentrate, declining grades.

Lab Work Up

Other Tests

drug toxicology testing, urine

Cushing’s syndrome

complete blood count (CBC)

cortisol, PM

cortisol, AM

cortisol, urine

hypothyroidism

complete blood count (CBC)

thyroid function tests (TFT)

thyroid-stimulating hormone (TSH)

free thyroxine (FT4)

attention deficit hyperactivity disorder (ADD/ADHD)

depressive disorder

mononucleosis, Epstein-Barr virus (EBV)

heterophile antibody test (mononucleosis spot)

complete blood count (CBC)

anemia

complete blood count (CBC)

total iron-binding capacity (TIBC)

total serum iron (TSI)

pregnancy

human chorionic gonadotropin (hCG), urine

diabetes mellitus type 2

complete blood count (CBC)

glycated hemoglobin (HbA1c)

glucose, blood (BG)

Angela PHQ- A score was 19-

Johnson, J. (n.d.). PHQ-9 modified for adolescents (PHQ-A) [Pdf]. Http://www.uacap.org.

Treatment : NSG 6330 Week 2 Discussion iHuman Case Study – Angela Cortez

Angela will be referred to a psychiatrist for initiation of both psychotherapy and pharmacotherapy in treatment of adolescent depression. She will be started on fluoxetine, a selective serotonin reuptake inhibitor (SSRI), with upward dosage adjustment over several weeks. SSRIs plus cognitive-behavioral therapy (CBT) have been demonstrated to be effective in treating adolescent depression.

The initial management plan also includes the following actions:

• Review common side effects (nausea, vomiting, decreased appetite, sleep disturbance) with patient and parent. Review black box warning and risk of suicidality with patient and parent.
• Review and document assessment of patient’s suicide risk. Establish an oral no-suicide contract and a safety plan should suicidal thoughts develop while on medication. Clinician should ask about availability of firearms and other dangerous items in the home and request that they be removed.
• Educate patient and parent by providing verbal and written information about the prevalence, symptoms, and treatment of depression.
• Refer to a nutritionist to assess the patient’s nutritional risk factors for recent weight gain, and to assist the patient in setting goals to reduce BMI (dietary modification, behavioral modification, increased physical activity).
• Schedule follow-up appointment with primary care physician to assess response to therapy.
• NSG 6330 Week 2 Discussion iHuman Case Study – Angela Cortez

Bhatia S, Bhatia S. Childhood and adolescent depression. American Family Physician. 2007; 75(1).

Braverman PK, Breech L. Gynecologic examination for adolescents in the pediatric office setting. Pediatrics. 2010; 126(3):583-590.

Brent D, Birmaher B. Adolescent depression. New England Journal of Medicine. 2002; 347(9).

Cheung A, et al. Guidelines for adolescent depression in primary care (GLAD-PC): II. Treatment and ongoing management. Pediatrics. 2007; 120;e1313.

March J, et al. Fluoxetine, cognitive behavioral therapy, and their combinations for adolescents with depression: Treatment for adolescents with depression study (TADS): Randomized controlled trial. JAMA. 2004; 292(7):807-820.

Moses S. Female Tanner stage. Family Practice Notebook. 2014

Prager LM. Depression and suicide in children and adolescents. Pediatrics in Review. 2009; 30(6):199-206.

Rome E. Obesity prevention and treatment. Pediatrics in Review. 2011; 32(9):363-372.

Saluja G, et al. Prevalence of and risk factors for depressive symptoms among young adolescents. Archive of Pediatric and Adolescent Medicine (JAMA).

Schneider M, Brill S. Obesity in children and adolescents. Pediatrics in Review. 2005; 26(5):155-161.

Williams S, et al. Screening for child and adolescent depression in primary care settings: A systematic evidence review. U.S. Preventive Services Task Force Report. Pediatrics. 2009; 123:e716-e735.

SAMPLE

Angela Cortez is a 17-year-old female who presents with a history of fatigue and lack of energy for the past two months; associated with irritability and weight gain. Her symptoms have led to a decline in her school performance and lack of participation in her usual activities. She has been crying on a near daily basis over the past month. On physical exam, she has an elevated BMI, is tearful, and is noted to have acne, striae, and acanthosis. She denies any active suicidal thoughts (i-Human).

Describe the evaluation tool and explain why this tool is essential in the care of the adolescent patient population.

Patient Health Questionnaire (PHQ-9) Modified for Adolescents (PHQ-A) is a self-administered instrument that assesses anxiety, eating, mood and substance use disorders among adolescent primary care patients. It is essential in this population due to the high risks of this age group and the need to assess for and manage/treat mental health disorders.

Apply the findings of the scholarly research articles to the use of this evaluation tool and describe its validity and reliability.

According to the Journal of Adolescent Health findings support the diagnostic validity of the PHQ-A. The PHQ-A and the clinical interview produced similar estimates of the prevalence rates of anxiety, eating, mood, and substance use disorders. The PHQ-A demonstrated satisfactory sensitivity, specificity, diagnostic agreement, and overall diagnostic accuracy, compared with the clinical interview.  The PHQ-A may be used to assist primary care practitioners in identifying psychiatric disorders among their adolescent patients. The PHQ-A is the first such tool to be tested for use in adolescents and offers an acceptable and efficient tool for early detection and recognition of mental disorders in this high-risk group.

Apply this evaluation tool to a patient situation and summarize your opinion of the results

The PHQ-9 Modified for Adolescents PHQ-A was used to evaluate Angela regarding her current symptoms and changes in mood and behavior. Based on responses to the questionnaire and patient interview it is established that she has Depressive Disorder; scoring 19 on the PQH-9. More than half of her responses received a score of 3 in the nearly every day category for feelings, appetite, interests and concentration; for the past two weeks.

Describe a plan of care for the patient, depending upon the results

According to the American Family Physician the following is the client plan. Angela will be referred to a psychiatrist for initiation of both psychotherapy and pharmacotherapy in treatment of adolescent depression. As a first line agent she will be started on a selective serotonin reuptake inhibitor (SSRI); with titration over the course of several weeks. SSRIs plus cognitive-behavioral therapy (CBT) have been demonstrated to be effective in treating adolescent depression. The American Family Physician also takes this stance in regard to the PHQ-A; stating that this 9 item screening tool is more sensitive in adolescents than adults. NSG 6330 Week 2 Discussion iHuman Case Study – Angela Cortez

The initial management plan also includes the following actions:

• Review common side effects of medication with the client and family; especially black box warnings and risk of suicide.
• Assess patient’s suicide risk. Establish a no-suicide contract. Inquire about firearms in the home and accessibility.
• Provide education and information depression.
• Nutritionist referral for regarding healthy eating/choices and physical activity.
• Follow-up with PCP to assess management / therapy.

References

Gardner, W. (2014). Screening for Mental Health Problems: Does It Work? Journal of Adolescent Health,55(1), 1-2. doi:10.1016/j.jadohealth.2014.04.019

Ham, P., MD, & Allen, C., PhD. (n.d.). Adolescent Health Screening and Counseling. American Family Physician,86(12), 1109-1116.

Johnson, J. G., PhD, Harris, E. S., MD, & Williams, J. B., DSW. (n.d.). The patient health questionnaire for adolescents: Validation of an instrument for the assessment of mental disorders among adolescent primary care patients. Journal of Adolescent Health,30(3), 196-204.

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