Comprehensive Case Study

Identifying Data: S.C. is a 38-year-old Caucasian female referred to the clinic by her primary care provider for the management of severe depression. She is married and is accompanied by her husband during the clinical visitation. She is a reliable historian: Comprehensive Case Study.

Chief Complaint: “I am just tired of life. Everything is not working, and I cannot bear it anymore.”

HPI: 38-year-old Caucasian female presenting to the clinic with complaints of being tired of life upon recommendation by her primary care provider. The symptoms began over a year ago. The patient has a low mood during most of the day. She also lost pleasure in things she once considered pleasurable, such as reading novels and watching her favorite television shows.

She also reports having low energy and being unable to adequately perform her motherly and wife duties, such as preparing her children for school. Her husband notes that the patient sleeps a lot, is easily distracted, and has since been dismissed from her job for poor performance. She also cries a lot and feels bad for being unable to provide for the family and perform her duties as a wife and mother.

The patient has developed an increased appetite and has since gained weight. The symptoms appear most of the day. They are aggravated during her stressed moments, such as when she is required to perform domestic duties and when she is at work, and are improved by reassurance from her husband.

Past Psychiatric History: The patient was diagnosed with persistent depressive disorder 15 years ago. She was started on psychotherapy to manage the disorder and was considered depression free after one and a half years. The patient has recently had two failed suicidal attempts and continues to contemplate another suicidal attempt.

Medical History: The patient was hospitalized for COVID-19 last year. She, however, denies any other hospitalization, head injuries, or any other physical illnesses. The patient is up to date with all her childhood and adulthood vaccines.

Substance Use History: The patient currently drinks and smokes socially. She drinks alcohol and smokes during social events. She denies using illicit substances.

Family History: The mother was diagnosed with substance use disorder and is currently in rehabilitation. The father is a chronic alcoholic. He was convicted of child abuse after brutally beating and injuring her brother. She has two siblings, aged 35 and 32. All of her family members are still alive.

Personal History

Perinatal History:  The patient was born at full term through vaginal delivery. She has a history of perinatal exposure to alcohol and smoking. Her mother was a chronic alcoholic and smoker and consumed alcohol and smoked even during her pregnancy. She was exclusively breastfed through her first year of life.

Childhood: The patient was forced into foster care at the age of five. This was attributed to the risk of exposure to violence, as evidenced by having alcoholic parents and frequent domestic fights between her parents. Her two siblings were also taken under foster care.

Adolescence: The patient spent the majority of her adolescence in foster care. She had her first alcohol and smoking exposure at sixteen. She also had her first sexual contact at seventeen. She performed moderately at high school and never encountered any major disciplinary concerns.

Adulthood: The patient was married at 28. She has two healthy children, aged 6 and 8. She used to work as a line operator at a local manufacturing plant but was dismissed early this year after a series of poor performances. She used to sleep off at work and did meet her work deliverables. The patient has never been convicted of any crime.

Trauma/Abuse History: The patient was exposed to significant domestic violence during her early years. She was physically abused by her parents several times. She also witnessed her parents fighting several times. She was rescued from a rape attempt by one of her mother’s boyfriends at the age of four.

Cultural History: The patient is a Caucasian. She expresses her strong belief in the ability of Westernized medicine to alleviate her suffering. Her parents were also Caucasians and ensured she received all her childhood vaccines.

Mental Status Exam

Appearance: The patient seems tired and in distress. She is also dressed and groomed for the occasion. She can maintain an erect posture during the interview and can maintain eye contact with the caregiver.

Behavior & psychomotor activity: The patient is able to interact with the caregiver normally, with no signs of agitation. Her mannerisms are also intact. There are no signs of tics, unusual movement, hyperactivity, unintentional movements, or automatism.

Consciousness/orientation: The patient is alert and responsive to the interview questions. She is oriented to place, time, and event.

Memory: The patient’s memory is intact. She can recall recent, remote, and immediate events. She can verbalize her reason for healthcare seeking and events in the last 5 to 10 minutes.

Concentration & attention: Her concentration and attention are intact.

Visuospatial ability: Her visuospatial ability is intact.

Abstract thought: Abstract thought patterns are logical and goal-directed. No signs of flight of ideas or incoherent thoughts.

Intellectual functioning: Intellectual functioning is intact.

Speech and Language: (quantity, rate, etc…): Speech is goal-directed and intact. No signs of significant changes in intonation, quantity of speech, or slurred speech.

Perceptions: No signs of hallucinations or delusional perceptual patterns.

Thought processes: The thought process is logical, goal-directed, and coherent.

Thought content: Thought content is logical, coherent, and goal-directed. No sign of a flight of ideas.

Suicidality: The patient has had two suicidal attempts in the past two months.

Mood: Mood is dysphoric. The patient feels depressed and overwhelmed.

Affect: Affect is dysphoric and sad.

Impulse control: Her impulse control is intact.

Judgment/insight/reliability: Judgment is goal-directed and logical.

Diagnoses

Differential diagnoses:

1. Major depressive disorder ICD-10 Code F32.2: Major depressive disorder is a psychiatric disorder characterized by persistent low mood and anhedonia. Other symptoms of MDD include a feeling of guilt, hopelessness, being overwhelmed, worthlessness, lack of energy, appetite changes, suicidal tendencies, and attempts and insomnia (Cui et al., 2024). The presence of persistent depressed mood, anhedonia, lack of energy, appetite changes, and feeling of being overwhelmed warranted the inclusion of this differential.
2. Bipolar disorder ICD-10 Code F31.9: Bipolar disorder is characterized by alternating episodes of depression and mania (Nierenberg et al., 2023). The presence of depressive manifestations, such as persistent low mood and anhedonia, warranted the inclusion of this differential. The absence of manic manifestations in the case presented in the case presented made this diagnosis less probable.
3. Dysthymia ICD-10 Code F34.1: Dysthymia is a probable diagnosis in the presence of depressive episodes lasting more than two years (Nübel et al., 2020). The presence of depressive manifestations, such as a feeling of being overwhelmed, depressed mood, and anhedonia, warranted the inclusion of this differential.

Final Diagnosis: The presumptive diagnosis is major depressive disorder ICD-10 Code F32.2:  The presence of persistent low mood, anhedonia, social disruptions, lack of energy, feeling or being overwhelmed, and multiple suicidal attempts and ideations signifies severe major depressive disorder (DSM-V). The patients in the case presented may have a severe major depressive disorder. Persistent depression was ruled out as the period of symptoms was less than 2 years (Nübel et al., 2020).

Assessment Tools: The Patient Health Questionnaire-9 (PHQ-9): PHQ-9 can be used to monitor the progress of MDD. It measures apparent manifestations of MDD, scoring the disease as mild, moderate, or severe. It can be used to inform therapeutic measures to take for the patients and assess their response to therapy.

PHQ-9 has excellent reliability with a score of Cronbach’s alpha values of between .79 and .89. It also has a diagnostic validity score of 89% and a specificity score of 88% for major depressive disorder. This score means the tool is reliable and valid in diagnosing MDD and monitoring disease severity in patients with MDD (Shaff et al., 2024).

Treatment Strategy

Evidence-based treatment/or practice guidelines: According to the DSM-V criteria for diagnosing major depressive disorder, a positive diagnosis is made in the presence of persistent low mood and anhedonia that results in social impairment for the patients. The symptoms must be present for at least six months and accompanied by symptoms such as feelings of guilt, worthlessness, lack of energy, insomnia, and appetite changes (DSM-V). The presence of depressive manifestations, lasting for more than six months and resulting in the patient losing her job, affirmed the diagnosis. Also, suicidality signified severe major depressive disorder (Karrouri et al., 2021)

Safety Measures: The presence of suicidal ideations and previous attempts demonstrate significant safety compromise for the patient. Close monitoring and clinical admission is warranted to prevent further attempts (Karrouri et al., 2021).

Psychopharmacology: The patient will be started on Fluoxetine at a dose of 10mg administered orally every 24 hours. The dose can be increased to 20mg as tolerated by the patient. Fluoxetine is a selective serotonin reuptake inhibitor (SSRI). SSRIs are the first line in managing MDD. They are effective in alleviating depressed mood and preventing suicidality. They are also highly tolerable (Karrouri et al., 2021). This makes them the medication of choice for patients with MDD.

Diagnostic Tests: Toxicological screening may be necessitated to rule out substance use disorder as a causal factor for major depressive disorder. A complete blood count with differential and metabolic panel may also be conducted to rule out organic and other medical causes of depression (APA, 2019).

Referral/Psychotherapy: The patient will be referred to a psychotherapist for psychotherapy. She will be required to attend CBT sessions to help address her symptoms. Combining CBT and pharmacotherapy is superior to either agent when used alone in managing severe depression. It is thus important that the patient is referred to a psychotherapist to fast-track her healing process (APA, 2019).

Psychoeducation: The patient will be educated on the disease process. She will be told that depression is a serious psychiatric illness that, if left unmanaged, can result in suicidality. She will also be told the significance of adhering to the prescribed medication in symptomatic alleviation and quality of life improvement (APA, 2019).

Follow-Up: After two weeks, the patient will be required to return to the clinic for follow-up. During the clinical visitations, her response to the medications will be assessed, which will inform medication escalation or revision.

References

APA. (2019, August). Clinical practice guideline for the treatment of depression across three age cohorts. American Psychological Association. https://www.apa.org/depression-guideline

Cui, L., Li, S., Wang, S., Wu, X., Liu, Y., Yu, W., Wang, Y., Tang, Y., Xia, M., & Li, B. (2024). Major depressive disorder: Hypothesis, mechanism, prevention and treatment. Signal Transduction and Targeted Therapy, 9(1). https://doi.org/10.1038/s41392-024-01738-y

DSM-V. (n.d.). DSM. Psychiatry.org – DSM. https://www.psychiatry.org/psychiatrists/practice/dsm

Karrouri, R., Hammani, Z., Benjelloun, R., & Otheman, Y. (2021). Major depressive disorder: Validated treatments and future challenges. World Journal of Clinical Cases, 9(31), 9350–9367. https://doi.org/10.12998/wjcc.v9.i31.9350

Nierenberg, A. A., Agustini, B., Köhler-Forsberg, O., Cusin, C., Katz, D., Sylvia, L. G., Peters, A., & Berk, M. (2023). Diagnosis and treatment of bipolar disorder. JAMA, 330(14), 1370. https://doi.org/10.1001/jama.2023.18588

Nübel, J., Guhn, A., Müllender, S., Le, H. D., Cohrdes, C., & Köhler, S. (2020). Persistent depressive disorder across the adult lifespan: Results from clinical and population-based surveys in Germany. BMC Psychiatry, 20(1). https://doi.org/10.1186/s12888-020-2460-5

Shaff, J., Kahn, G., & Wilcox, H. C. (2024). An examination of the psychometric properties of the Patient Health questionnaire-9 (PHQ-9) in a multiracial/ethnic population in the United States. Frontiers in Psychiatry, 14. https://doi.org/10.3389/fpsyt.2023.1290736

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This case study should be guided by the standards of practice for the professional psychiatric mental health nurse practitioner. The case study should be corroborated by sound evidence-based evidence and individualized to your patient. It should be written as if you are presenting this to a professional meeting or to a colleague. You should construct this comprehensive case study on an interesting adult patient encountered in your clinical practicum.

Writing should be succinct and to the point. Proofread and check for grammatical errors and flow of thoughts. Glean all the information you can about your patient through interviews, chart review, talking with your preceptor and other clinical staff.

If you are unable to obtain some information, please include that the data was not available but state and explain what normal findings would include. Write the history in chronological order.

To help you with construction of the comprehensive case study, review materials from previous courses, from this course, and from relevant scholarly materials. You must have a minimum of three (3) references and these should be from peer-reviewed sources (at least one of these should be 5 yrs old or less) in addition to your required textbooks.

In your paper, use a pseudonym for your patient. Do not identify the state or town where your encounters took place. Describe the area as rural, urban, township, city, large city, northeast, northwest, southwest state, etc.

Choose a patient who provides a good learning opportunity. The patient should have a sufficient history to be included and the history should support the diagnosis. You should not focus on each section with the goal of just satisfying points…. you must develop each section to show your ability to critically think as you move the reader toward the appropriate diagnosis and plan for the patient.

The faculty reader should be able to follow your train of thinking in the development of each section.

Course Number: NU 652

Student Name:

Faculty:

Preceptor:

Date/time:

DATA	Points
Demographics: (age, gender, occupation, marital status, ethnicity, religion, current living circumstances, geographical location, language, etc.)	2
Chief Complaint: (use patient’s own words)	2
History of present illness: (what brought them to treatment, onset, current episode, precipitating factors or stressors)	4
Past psychiatric history: (first episode, treatments, medications, suicidal attempts, behaviors)	4
Medical history: (include all major medical illnesses, surgeries, tumors, seizures, infectious diseases, exposures to toxins or other environmental hazards, sexually transmitted diseases, immunizations, recent international travel, current medications)	3
History of drug or alcohol abuse: (patterns of use [illicit or prescribed] and abuse, hx of substance related black-outs, behaviors, seizures)	3
Family history: (psychiatric illnesses, substance abuse—go back to both sets of grandparents, hospitalizations)	4
PERSONAL HISTORY
Perinatal: (exposure to drugs or alcohol, full-term, pre-mature, vaginal, c-section, bottle or breast fed)	2
Childhood: (developmental milestones, history of self-stimulation (head banging, other repetitive behaviors), gender identity development, friendships, learning achievements and/or disabilities, motor skills, other behaviors such as bedwetting, cruelty to pets, etc.)	4
Adolescence: (school affiliations, groups, cliques, clubs, sports, self-esteem, sexual activity, body image)	4
Adulthood: (employment, marriage, activities, relationships, legal, education, etc.)	4
Trauma/abuse history: Describe any exposure to violence or trauma, including sexual, physical, emotional…..	4
Cultural history:  Include 1-2 paragraphs about this patient’s cultural background which affects their being or present way of living (may include medical or healing practices, any necessary accommodations)	3
MENTAL STATUS EXAMINATION
Appearance:	1
Behavior & psychomotor activity:	1
Consciousness/orientation	1
Memory: recent, remote, immediate	1
Concentration & attention:	1
Visuospatial ability:	1
Abstract thought:	1
Intellectual functioning:	1
Speech and Language: (quantity, rate, etc…)	1
Perceptions:	1
Thought processes:	1
Thought content:	1
Suicidality or homicidality:	1
Mood:	1
Affect:	1
Impulse control: (consider butting in, inability to control immediate reactions)	1
Judgment/insight/reliability:	1
DIAGNOSES
Differentials: Three (3) differential diagnoses including all symptoms, presentation, that are considered	6
DSM-5-TR Final diagnosis with ICD-10 code: Include all diagnosis specifiers	3
Assessment tools: How would you measure future progress? What tools would you use to measure? Include test name, reliability, validity, score ranges, meaning of scores, how often to administer, and present score if used.	5
TREATMENT STRATEGY
Evidence-based treatment/or practice guidelines: Support diagnosis, clinical presentation with references	4
Safety measures:	4
Psychopharmacology: Include pharmacodynamics, appropriate dosage, pharmacokinetics. Explain why this medication was chosen over others in this category.	4
Diagnostic tests: Include what is recommended and the rationale for these choices.	4
Referrals/psychotherapy: Reference the article to support this.	4
Psychoeducation: side effects, diagnosis, black box warnings, educational websites and other sources.	4
Follow up: Provide instructions that you would give the patient for side effects, emergencies, diagnostic and/or lab tests and frequency.	1
APA: Reference page, evidence-based articles, appropriate formatting	1
TOTAL POINTS	100

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