4/29/2019 Topic: Week 3: Psychiatric Disorders and Screening

https://chamberlain.instructure.com/courses/40085/discussiontopics/1033971?moduleitemid=48669701/57

This is a graded discussion: 50 points possible due Mar 24

Week 3: Psychiatric Disorders and Screening

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Anxiety and depression are the most common psychiatric problems you will encounter in your primary care practice.

Review this case study

HPI: KB, 55 year old Caucasian female who presents to office with complaints of fatigue. The fatigue has been present for 6 months

and seems worse in the morning, improving slightly through the day. KB reports a lack of energy and "loss of joy". States" I really

don't feel like going anywhere or doing anything" Reports she often has difficulty staying on task and completing projects for work.

She reports not feeling hungry and does not feel rested when she wakes up in the morning. KB is a widow for 2 years, social events

that are couples only can make her symptoms worse. She tries to do at least one social activity a week but it can be really

exhausting. Her husband died in their car while she was driving him to the hospital and sometimes driving in that car makes all the

memories come back. She recently got a puppy, which she thought would help with the loneliness but the care of the puppy seems

overwhelming at times. Rest and exercise, specifically yoga and meditation seem to make her feel better. At this time she does not

want to do either. She has not tried any medications, prescribed or otherwise. She reports drinking a lot of coffee, but that does not

seem to help.

Current medications: Excedrin PM about once a week when she can't sleep, seems to help a bit. NKDA.

PMH: no major illnesses. Immunizations up to date.

SH: widowed, employed full time as a manager. Drinks wine, 1 glass every night. No tobacco, no illicit drugs. Previously married

while living in France, reports an abusive relationship. The French government gave custody of her son to the ex-husband. She

returned to US without her son 10 years ago. She sees her son two times a year, they skype and text "all the time" but she misses

him.

FH: Parents are alive and well. Has one son, age 21, he is healthy but lives in France with his father.

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4/29/2019 Topic: Week 3: Psychiatric Disorders and Screening

https://chamberlain.instructure.com/courses/40085/discussiontopics/1033971?moduleitemid=48669702/57ROS

CONSTITUTIONAL: reports weight loss of 2-3 pounds, no fever, chills, or weakness reported

HEENT: Eyes: No visual loss, blurred vision, double vision or yellow sclera. Ears, Nose, Throat: No hearing loss, sneezing,

congestion, runny nose or sore throat.

CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations or edema.

RESPIRATORY: No shortness of breath, cough or sputum.

GASTROINTESTINAL: Reports decreased appetite for about 3 months. No nausea, vomiting or diarrhea. No abdominal pain or

blood.

NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel

or bladder control.

GENITOURINARY: no burning on urination. Last menstrual period 4 years ago.

PSYCHIATRIC: No history of diagnosed depression or anxiety. Reports great anxiety due to verbal and concern for physical abuse,

reports feeling very sad and anxious when divorcing and leaving her son in France. Did not seek treatment. She started to feel

better after about 4 months.

ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. No polyuria or polydipsia

ALLERGIES: No history of asthma, hives, eczema or rhinitis.

Discussion Questions:

1. Research screening tools for depression and anxiety.

Choose one screening tool for depression and one screening tool for anxiety that you feel are appropriate to screen KB.

Explain why you chose that particular tool for KB. Score KB based on the information provided (not all data may be provided).

Include what questions could be scored, and your chosen score. Assume that any question topics not mentioned are not a concern

at this time.

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2. Identify your next step for evaluation and treatment for KB. Include any necessary physical medicine evaluation.

3. What medication, if any, would you recommend for treatment? Provide the rationale. This should include the medication class,

mechanism of action of the medication and why this medication is appropriate for KB. Include initial prescribing information and

education to include side effects and when KB should notice efficacy.

4. If the medication works as expected, when should KB expect to start feeling better?

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Mar 19, 2019

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Week 3: Psychiatric Disorders and Screening:

Hi Dr. Mompoint and Class,

Discussion Questions:

Research screening tools for depression and anxiety.

Choose one screening tool for depression and one screening tool for anxiety that you feel are appropriate to screen KB.

The 2 screening tools I have chosen to discuss is the Hamilton Depression Rating Scale (Ham-D) and Hamilton Anxiety Scale

(Ham-A). Both these tools are readily available online fore easy access and scoring. They can be found on Mdcalc.com, a great

tool for scoring the depression / anxiety in the office in a quick efficient manner. The original HAM-D has 21 items, but scoring is

based only on the first 17 so imputing those answers will definitely give the provider enough information to see if they need to

move forward with treatment (Hamilton Depression Rating Scale (HAM-D), 2019). The Ham-A test is very useful for evaluating

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4/29/2019 Topic: Week 3: Psychiatric Disorders and Screening

https://chamberlain.instructure.com/courses/40085/discussiontopics/1033971?moduleitemid=48669704/57new patients to assess their level of anxiety and functioning, as well as, trending a patient’s anxiety level over time (Hamilton

Anxiety Scale (HAM-A), 2019).

Explain why you chose that particular tool for KB. Score KB based on the information provided (not all data may be

provided). Include what questions could be scored, and your chosen score. Assume that any question topics not

mentioned are not a concern at this time.

I chose these two particular tools for KB, because they are both easy, efficient, valid and reliable instruments that have been

proven effective (Hamilton Depression Rating Scale (HAM-D), 2019). They both assess the severity of psychological and

somatic symptoms of depression / anxiety, and therefore maybe used to screen for depression/anxiety as well as evaluate the

efficacy of psychotherapeutic interventions for patients once in place (Hamilton Depression Rating Scale (HAM-D), 2019). I

particularly liked these tools since they evaluate for somatic and cognitive signs and symptoms of anxiety / depression and it

also includes a clinician observation rating of the patient’s behavior (Hamilton Anxiety Scale (HAM-A), 2019).

KB score for the Hamilton Depression Rating Scale (Ham-D) based upon the case study information is a 17 which indicates

moderate depression. The way the test works is that 8 items are scored on a 5-point scale from 0–4, and 9 items are scored on

a 3-point scale from 0–2. For these 17 items, 0 reflects absence of the particular symptom and each consecutive number

indicates increasing symptom severity (Hamilton Depression Rating Scale (HAM-D), 2019). The total scores on the HAM-D

range from 0–54; total score interpretation is as follows: 0–7 indicates lack of clinical depression, 8–13 indicates mild

depression, 14–18 indicates moderate depression, 19–22 indicates severe depression, and ≥23 indicates very severe

depression. KB has reported sadness +1, (did not report any weeping / crying) she does have mild guilt / sadness /anxiety from

loosing custody of her son which is a +1. The case study did not mention suicidal ideations or insomnia, so I marked it absent.

Scoring work interest / lack of interest I gave her a +3 Productivity decreased as she reported not feeling like going anywhere or

doing anything. I gave her a +1 for Slowness of thought, speech, and activity; apathy; stupor since she reports difficulty staying

on task and completing projects for work. I marked agitation as absent since the case study did not mention any. Regarding

Psychiatric anxiety I gave her a +4 as she reports great anxiety due to verbal and concern for physical abuse. Somatic anxiety I

did +1 as she reports loss of appetite, Gastrointestinal somatic symptoms +2, General somatic symptoms +2, and weight loss +2

all due to the 2-3 lb weight loss and decrease in apatite reported. Regarding Genital symptoms, such as loss of libido, menstrual

disturbances and Hypochondriasis I marked absent since it was not mentioned in the case study. Based upon this score I would

referrer KB for appropriate mental health evaluation and/or psychotherapeutic interventions to improve mood and promote

safety (Hamilton Depression Rating Scale (HAM-D), 2019).

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