Advance Healthcare
Subjective:
Chief Complainant: He states that he walks when he feels very anxious, but it seems nothing is working anymore.
Past Psychiatric History: The patient is a 17-year-old male. He reports to the clinic intermittent feelings of depression and anxiety. He reports that he has had a history of persistent depression and anxiety since middle school. His diagnosis is major depressive disorder, remission status, which is not specified, and recurrent. Further, the patient reports that he takes a walk when very anxious, but it appears that nothing is working anymore.
Social History: The patient is a middle school student who developed persistent depression and anxiety during school days. He reports feeling alone and taking a walk when he develops anxiety. The patient denies feeling hopeless, suicidal ideation, homicidal ideation, and auditory or visual hallucinations.
Family History: The case does not provide reports of the patient’s family history.
Health Promotion: The patient reports that he takes physical exercise by walking when he feels anxious.
Objective:
Weight (Not provided in the report)
BMI (Not provided in the report) Temperature (Not provided in the report) BP (Not provided in the report)
Height (Not provided in the report) Pulse (Not provided in the report) Respiratory (Not provided in the report)
Rated Depression: 5/10
Rated Anxiety: 4/10
General Appearance:
The patient appears to be depressed and anxious. However, he appropriately responds to the questions asked.
Skin: Reports of the patient’s skin condition are not provided in this case.
HEENT: Reports of the patient’s eyes, ears, head, nose, and throat are not provided in this case.
Psychiatric: The patient appears to be depressed and anxious. However, the patient averagely responded well to the questions asked during the assessment.
Assessment
Special tests: None
Primary Diagnosis
Depression ICD 10- F32.9: This condition manifests in the patient as symptoms including social withdrawal, anxiety, and depression. This condition is identified by signs including impaired social ties, as was the case with the patient. It is the most common diagnosis since it affects boys frequently during adolescence (Jones et al., 2018). Major Depressive Disorder, Single Episode, Unspecified, has the diagnostic code F32.9. It is a mental illness characterized by persistent emotions of depression, hopelessness, exhaustion, and trouble navigating daily life. Other signs of depression include sadness and feelings of worthlessness, lack of enjoyment in activities, adjustments to sleeping or eating patterns, and suicidal thoughts. Considering the thorough evaluation of the patient, this condition becomes the primary diagnosis.
Differential Diagnosis
Anxiety Disorder ICD 10- F41.9: The DSM-5 criteria can be used to identify this condition. The diagnostic code for anxiety disorder, unspecified, is F41.9. It is a group of psychiatric diseases defined by fearful or anxious feelings frequently accompanied by physical signs of anxiety. This condition precedes the signs of depression. Instead of explicitly occurring in a mood disorder, the symptoms of this illness instead manifest as anxiety symptoms when there are no signs of a mood problem (Kuriakose, 2018). Muscle tension, headaches, and perspiration are signs of this condition, excluding it from the primary diagnosis. A patient may also exhibit restlessness, impatience, and false perceptions of the world.
Plan
The patient endorsed good sleep with Trazodone 50mg table but took one tablet oral route bedtime PRN insomnia. The class of medications known as serotonin receptor antagonists and reuptake inhibitors includes the antidepressant trazodone (SARIs). Despite not belonging to the selective serotonin reuptake inhibitor (SSRI) class of antidepressants, trazodone exhibits many characteristics (Kuriakose, 2018). Treatment for major depressive disorder with trazodone. It might assist in enhancing the energy level, appetite, and mood and reducing depression-related anxiety and insomnia. Trazodone works by restoring the proper serotonin level in the brain, one of the body’s natural chemicals.
The symptoms of depression, obsessive-compulsive disorder, panic disorder, social phobia, and generalized anxiety disorder are all treated with Paxil. The medication may be taken either on its own or with other drugs. For the treatment of depression, panic disorder (abrupt, unexpected bursts of severe terror and worry about these attacks), and social anxiety disorder, Paxil is available as tablets, suspension (liquid), and extended-release tablets (Ma et al., 2018). Additionally, generalized anxiety disorder (GAD), characterized by excessive concern that is challenging to regulate, posttraumatic stress disorder, and obsessive-compulsive disorder, are all treated with Paxil tablets and suspension. Finally, Vistaril 50 mg 1 cap 6 hrs pm anxiety. Vistaril treats anxiety symptoms (Ma et al., 2018). Vistaril is a fantastic option if you have allergies and anxiety because it is also given as an antihistamine to treat skin allergies. Medical professionals occasionally use it as a sedative before treatment.
In this plan, cognitive behavioral therapy will be taken into account because the patient will receive counseling to help lessen the depression symptoms that are now being experienced. The patient will receive this therapy for six weeks, at the end of which the desired results will be shown (Ma et al., 2018). The patient is informed of the significance of taking prescribed medications as directed by a doctor. Thyroid function testing will also be part of the strategy, which will aid in deciding how to proceed with the treatment. The patient will return to the clinic for follow-up if the symptoms do not get better during the first two weeks of the treatment plan. If necessary, a psychiatrist will be recommended.
References
Jones, P. J., Mair, P., Riemann, B. C., Mugno, B. L., & McNally, R. J. (2018). A network perspective on comorbid depression in adolescents with obsessive-compulsive disorder. Journal of anxiety disorders, 53, 1–8. http://www.mcnallylab.com/wp-content/uploads/Jones-et-al.-2018-Journal-of-Anxiety-Disorders.pdf
Kuriakose, M. (2018). Parental alcoholism and its relationship with adolescents’ depression and self-concept. International Journal of Current Research in Life Sciences, 7(04), 1696-1698. http://www.iraj.in/journal/journal_file/journal_pdf/14-456-152966259026-28.pdf
Ma, Y., Siu, A., & Tse, W. S. (2018). The role of high parental expectations in adolescents’ academic performance and depression in Hong Kong. Journal of family issues, 39(9), 2505-2522. https://journals.sagepub.com/doi/abs/10.1177/0192513X18755194
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