Description
Subjective- P.J is a 45-year-old male presenting with feelings of sadness, fatigue, insomnia, and loss of interest in daily activities x 2 weeks. Denies suicidal ideation, history of depression, and family history of depression. Denies smoking tobacco, marijuana use, alcohol, and recreational drug use. Reports he is going through a divorce and is concerned he has gained weight. Has felt this way daily, lacks motivation to go to work, prefers to be secluded at home, overeats, stays indoors, and has not tried anything to help alleviate his feelings.
ROS- General: (+) Fatigue, weight gain
Head: (-) Denies head injury, headaches
GI: (-) Denies changes in bowel movements.
Musculoskeletal: (-) Denies muscle and joint pain
Neuro: (-) Denies numbness, tingling, memory loss, and vertigo
Psych: (-) Denies suicidal ideation (+) Depressed feelings, sadness, loss of interest
in hobbies/daily activities
Objective- BMI 31, Vital Signs: 123/76, HR 70, Temp 98.7, R 16, 99% RA, no pain.
General-Alert and oriented, low volume/slow rate of speech, slumped posture, downcast
eyes, hygiene is appropriate.
Psych- Denies suicidal ideation.
Thyroid- No cervical lymphadenopathy
Heart- S1S2 heard, no extra sounds, clicks, rubs, or murmurs.
Lung- Lung sounds clear to auscultation to bilateral bases.
Assessment-
Differentials:
Major Depressive Disorder- Fatigue, insomnia, can increase/decrease appetite, loss of interest.
or motivation in daily activities, including hobbies or work.
Hypothyroidism- Can cause feelings of fatigue, weight gain, insomnia.
Electrolyte deficiency- May lead to feeling fatigue and depressive moods. (APA, 2023)
Patient Health Questionnaire (PHQ-9)- scored 10, moderate depression (APA, 2023)
Labs: CBC, CMP, TSH/T3/T4 = Reviewed. WNL
Plan-
Daily exercise for a minimum of 30 minutes, such as daily walks, yoga, gardening, or aerobic.
Adoption of a Mediterranean diet
At least 15 minutes of daily sunshine
Music therapy, breathing techniques, or massage.
Shut off electronics 1-2 hours before bedtime.
Counseled patient on beginning SSRI. Shared decision making, patient verbalized would like to begin pharmacotherapy.
Sertraline 25 mg PO qDay #30 0RF (USPSTF et al., 2023)
Begin first dose today. May notice some changes within 2 weeks, but more noticeable changes within 4 weeks.
Follow-up in 1 month for re-assessment of medication, physical examination, and repeat of PHQ-9 test (or sooner if symptoms worsen).
If medication and non-pharmacological recommendations do not alleviate symptoms in one month, will discuss with patient increasing dose first before making a psych referral.
Resources:
American Psychological Association. (2023). Depression treatments for adults. American Psychological Association. https://www.apa.org/depression-guideline/adults/
Epocrates (2023). Epocrates medical references (Version 23.9.1) [Mobile app]. App store.
https://itunes.apple.com/us/app/epocrates/id234195…
US Preventive Services Task Force, Barry, M. J., Nicholson, W. K., Silverstein, M., Chelmow,
D., Coker, T. R., Davidson, K. W., Davis, E. M., Donahue, K. E., Jaén, C. R., Li, L.,
Ogedegbe, G., Pbert, L., Rao, G., Ruiz, J. M., Stevermer, J. J., Tsevat, J., Underwood, S.
M., & Wong, J. B. (2023). Screening for Depression and Suicide Risk in Adults: US
Preventive Services Task Force Recommendation Statement. JAMA, 329(23), 2057–2067.
https://doi.org/10.1001/jama.2023.9297
