CASE STUDY-Seasonal Affective Disorder

Seasonal Affective Disorder

Part 2- Turning in your final treatment plan and Analysis  

The final treatment plan will include the primary diagnosis, diagnostic testing recommended by National Guidelines. Medications, interventions, education, labs, follow up, referrals. After completing the treatment plan include the following sections in a large area called ANALYSIS:

1. Pathophysiology and Pharmacology: For the primary diagnoses in the case, write a brief summary of the underlying pathophysiology and tie pharmacological treatment chosen in the reversal or control of that pathology.

2. Additional analysis of the case: This includes national guidelines that were or should have been used to make diagnosis or treatment and review how they applied or how care was unique but based in guidelines.

3. Follow-up/Referrals: This means how the patient was doing when seen a second time if this applies. This would be their response to your plan of care. OR when Follow up will occur and what actions will be taken on the follow up visit. Referrals if indicated.

4. Quality: Include anything that should have been considered in hindsight or changes you would make in seeing similar patients in the future with the same complaint, history, exam, or diagnosis. Add anything you learned from discussion in the class that shed new light on this patient.

5. Coding and Billing. Any or all CPT and ICD-10 codes that should have been used (List them and name them only.

Mental illness goes undiagnosed in so many individuals living in the United States. Studies have shown it to affect approximately one in every five (19 percent) of adults. The American Psychiatric Association (APA) (2019) defines mental illnesses as health conditions affecting deviations in emotion, thinking or behavior (or a combination of these). These illnesses are also coupled with distress and/or difficulties acting in social, work or family events.

Case study:

George is a 27-year-old, single, Caucasian male who came to the clinic seeking medication for his fatigue, lack of energy, reduced sex drive and withdrawn behavior. Which he states this feeling happens to him all the time, around this time of year(winter) for the past 2 years.

Patient Information:

G.A. 27-year-old Caucasian male

CC (chief complaint): fatigue, lack of energy, reduced sex drive, and withdrawn behavior

HPI: G.A. is a 27-year-old, single, Caucasian male who came to the clinic seeking medication that will help with his fatigue, lack of energy, reduced sex drive, and withdrawn behavior. He stated that his symptoms had been harsh this year around wintertime and is now wanting to seek help because it has affected his personal life. He reported that he started feeling this way 2 years ago, and is becoming more withdrawn from the things that he normally enjoys doing. He denied seeking help because he was afraid of being labeled.

Current Medications: None.

Allergies: NKDA.

PMHx: Immunizations are current. Reports having no medical problems.

PSHx: None

Social Hx: Single Caucasian male. G.A. is an only child. He lives with his divorced mother. He denies drinking, smoking and illegal drug use.

Fam Hx: Father was an alcoholic and is now deceased from a motor vehicle accident 5 years ago. Mother 65 is alive and suffers from depression. No other pertinent family hx reported.

ROS:

Constitutional:  States he lost 10lbs in the last month. Negative for chills, fever, weakness, and night sweats

HEENT:   Eyes:  No visual loss, PERRLA. Ears, Nose, Throat:  No hearing loss, nasal congestion, or sore throat.

Skin:  Normal temperature, tone, texture, turgor and no rash or itching.

Cardiovascular: No chest pain, discomfort, and palpitations. No edema.

Respiratory: No shortness of breath. No cough or sputum.

Gastrointestinal:  No nausea, vomiting, diarrhea, or abdominal pain. Abdomen soft, non-tender, non-distended, bowel sounds active in all four quadrants.

Genitourinary:  No sign of dysuria or polyuria and voiding freely

Neurological:  No headache, dizziness, or syncope and numbness or tingling.

Musculoskeletal: No back pain, muscle, and joint pain or stiffness.

Hematologic:  Negative for bleeding or bruising.

Lymphatics:  Negative for enlarged nodes.

Psychiatric:  Family hx of depression (mother)

Endocrinologic: No polyuria or polydipsia.

Allergies: NKDA.

Physical exam:

Vital signs: BP 110/60, Pulse 100, Temp 36.1 C, Resp 20, Height 6′ 1″, Weight 170lb.

General: Flat affect, no eye contact, patient looks at floor while speaking. Speaks in a low tone

HEENT: Head normocephalic and atraumatic. Hair evenly distributed throughout the scalp. Eyes: Sclera clear. Conjunctiva: white, PERRLA, EOMs intact bilateral. Ears: Tympanic membranes gray and intact and no discharge or erythema. Nose: Nares normal, septum midline, mucosal pink and moist and no drainage or sinus tenderness. Throat: Lips, mucosa and tongue normal, no lesions or exudate. Neck. Supple, trachea midline, no tenderness, no cervical lymphadenopathy or nodules. No carotid bruit or JVD. Thyroid midline: small and firm without palpable masses.

Lungs: Lungs clear to auscultation bilaterally. Respirations even and unlabored.

Cardiovascular:  S1 and S2 normal, no murmur, rub or gallop. RRR, no displaced PMI. Peripheral pulses equal bilaterally, no peripheral edema.

Abdomen: Soft, non-tender, non-distended, bowel sounds present in all four quadrants. No hernias and no masses. No organomegaly.

Genitalia: Deferred.

Rectal: Deferred.

Musculoskeletal: Moves all extremities, good ROM, no edema

Skin: Warm to touch, normal tone, texture, turgor, no induration, no rash and no lesions.

Neurologic: Negative for any deficits

Psychiatric: Flat affect.

Reference:

American Psychiatric Association. (2019). What is mental illness? Retrieved from https://www. psychiatry.org/patients-families/what-is-mental-illness

Case Study:

Patient Information:

D.A. 32-year-old Caucasian male

CC: fearful of being around loud noises, terrible anxiety, memories of an explosion and nightmares.

HPI: D.A. is a 32-year-old, single, Caucasian male who came to the clinic seeking medication that will help with panic attacks, feeling fearful of being around loud noises, terrible anxiety, memories of an explosion and nightmares. He stated that his symptoms were harsh and that they started about one year after being around an explosion that took the lives of five men and women while he was in Baghdad two years prior. He reported serving two tours in the military. He reported that he started feeling this way a year now when he went out in public and heard bang noises from an old car muffler. He reported that any banging would trigger his feelings, and the symptoms would ease if he meditates and or take slow deep breaths. He reported the episode would last for twenty-four hours, and he reports becoming more withdrawn than usual. He denied seeking help because he was afraid of being labeled.

A:

Diagnosis: Post traumatic stress disorder, also called, PTSD. (F43.1)

One must understand that PTSD is a type of anxiety disorder that arises after exposure to a distressing incident such as threat of death, serious physical injury to and threat to physical well-being (Domino, Baldor, Golding, & Stephens, 2019).

Individuals affected must have a comprehensive management plan which are based on clinical practice guidelines, clinical judgment, patient preferences and the patient’s response to psychotherapy or psychopharmacology are completely vital factors in selecting the course of action or treatment for PTSD.

The clinical practice guidelines that should have been applied to D.A. are psychotherapies such as cognitive processing therapy (CPT) and eye movement desensitization and reprocessing (EMDR) (American Psychological Association, 2017) which is a newer nontraditional way of therapy along with medications such as Sertraline (Zoloft) or Paroxetine (Paxil) which are the only approved medications by the Food and Drug Administration (FDA) for PTSD (American Psychological Association, 2019).

The lessons learned from this discussion were the importance of thoroughly assessing one’s patients, being very attentive to details, listen to your patients and the need for making referrals beyond the scope of practice.

Final Treatment Plan/Analysis:

ANALYSIS

The research has shown that the pathophysiology of PTSD is unsure, however the evidence is suggestive of underlying methods include activation of the part of the brain that’s immersed in fear, volume loss of the hippocampus that’s involved in formation of memory (Lisieski, Eagle, Conti, Liberzon, & Perrine, 2018) therefore creating a need for medications such as SSRIs. These are known to play an active part in regulating mood and anxiety disorders.

The action of this neurotransmitter in both the peripheral and central nervous systems can be controlled by SSRIs (APA, 2019).

Medication prescribed:

Paroxetine (Paxil) 20 mg daily

Take one tablet by mouth once daily

Disp: #30

No Refill

Educate the patient on the possibility of side effects from the medication. It will take some weeks before the medication starts to work, and therefore taking the medication as prescribed is important.

Follow-up:

Psychiatrist and Psychologist and PCP in 2 to 4 weeks to reassess medication effect

Coding and Billing:

ICD-10 code is F43.1- Post-traumatic stress disorder (PTSD)

References

American Psychological Association. (2017). Clinical practice guideline for the treatment of posttraumatic stress disorder (PTSD) in adults. Guideline development panel for the treatment of PTSD in adults. Retrieved from https://www.apa.org/ptsd-guideline/ptsd.pdf

American Psychological Association. (2019). Clinical practice guideline for the treatment of post traumatic stress disorder: medications for PTSD. Retrieved from https://www.apa.org/ptsd-guideline/treatments/medications

Domino, F.J., Baldor, R.A., Golding, J., & Stephens, M.B. (2019). The 5-minute clinical consult 2019 (27th ed.). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins.

Lisieski, M. J., Eagle, A. L., Conti, A. C., Liberzon, I., & Perrine, S. A. (2018). Single-prolonged stress: A review of two decades of progress in a rodent model of post-traumatic stress disorder. Frontier in Psychiatry. Doi.org/10.3389/fpsyt.2018.00196

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