Jacqueline Russell iHuman Case Study

HPI (OLDCARTS)

Jacqueline Russell is a 17-year-old female who comes in the clinic with complaints of generalized fatigue which started two months ago. Accompanying symptoms include anxiety, anhedonia, irritability, and problems concentrating. Major life changes include recent breakup with her boyfriend and pressure in school while expected by her parents to have a scholarship. She stated that she gets enough sleep but still feel tired upon waking up. Key findings include being overweight, easily cries, unintentional 25-30 weight gain last year, history of marijuana use, Acanthosis Nigricans, and striae on abdomen and buttocks. She denies taking any medications other than Ibuprofen for menstrual cramps. She occasionally drinks beer. The patient skips breakfast but eats high calorie foods like pizza and French fries several times per week.

The patient denies any suicidal ideations but stated that she wants to “disappear” and not deal with her situation. Risk factors include family history of diabetes II and obesity. Lab findings are negative for anemia, negative urine drug screen, normal T4, TSH levels, and CBC.

Key Findings:

BMI 28.8 (overweight)

Patient is reluctant to make eye contact Crying

Pressure from being a senior at school

Mother made her come, pressure from parents Per patient gets enough sleep but wakes up tired Unintentional 25-30 weight gain last year Stretch marks

Marijuana use Hx with old boyfriend Breakup with boyfriend

Low self-esteem

Skips breakfast, eats high calorie foods like pizza and french fries several times per week Constantly snack at night to keep going

Anhedonia in school and leisure activities Upset, irritable, angry, frustrated, and cries daily

Feels irritable and annoyed a lot by family and parents, they blame on her periods. Problems concentrating daily

Wants to disappear and not deal with situation Occasionally drinks beer

Acanthosis Nigricans at nape Striae on abdomen and buttocks

Meds:

Takes Ibuprofen for menstrual cramps, pain is not bad per patient.

Social

Tried marijuana last year with old boyfriend, denies any other recreational drugs Used to baby sit for a family neighbor

Primary Dx:

Major Depressive Disorder – Symptoms similar to Jacqueline are depressed mood, irritability, markedly diminished interest and pleasure in usual activities, and symptoms that lasts at least two weeks. Common symptoms of depression also include change of appetite (25-30 lbs. weight gain), low energy and fatigue, and difficulty concentrating. MDD is diagnosed if there have been at least two weeks of depression with at least four accompanying symptoms of depression.

General Anxiety Disorder – The most common comorbidity with depression is anxiety disorder. Major symptoms similar to Jacqueline are unexplained fatigue, irritability, difficulty concentrating,

DDx:

Type II Diabetes Mellitus Hypothyroidism

Fatigue

O-2 months ago L-generalized

D-Constant per mother C-

A-Pressure from school as a senior

A-Gets enough sleep but still wakes up tired R-?

T-

S-Don’t feel like doing anything

1.      Therapeutic & Non-Therapeutic Modalities

Consider cognitive behavioral therapy and psychoeducation in collaboration with a pediatric psychiatrist. Antidepressant medications may be considered first-line treatment for moderate-to- severe depression or depression that has not responded to an adequate trial of psychotherapy

Family interventions and involvement in cognitive-behavior therapy

Fluoxetine (Prozac) 10 mg PO daily. Fluoxetine has the strongest evidence for use in pediatric depression (Mullen, 2018). May take at night if feelings of drowsiness occur during the day.

Have a healthy balanced diet that includes fruits, vegetables, whole grains, fat free or low-fat milk, lean meats, eggs, and seafood.

Engage in a 60 minute or more of moderate to vigorous intensity physical activity each day. Activities may include aerobics, running, jumping, and muscle-strengthening (climbing, push- ups).

Get enough quality sleep. The Centers for Disease and Control and Prevention (CDC) recommends 8-10 hour per 24 hours of sleep for teens 13-18 years of age (CDC, 2021)

2.      Additional Labs or Diagnostic Tests

Children’s Depression Inventory (CDI) scale or PHQ-9 modified scale for teens Type II Diabetes Mellitus – HbA1c level, Random fasting glucose Hypothyroidism – Thyroid stimulating hormone (TSH) and free T4

Anemia – Complete blood counts (CBC)

Urinalysis – Rule out infection since it mimics depression symptoms in female children and adolescents (Dunphy et al., 2015). Screen for sexually transmitted infection.

Urine Pregnancy Test – Since the patient is at childbearing age and taking Fluoxetine may increase the risk of cardiovascular malformations in infants (Gao et al., 2017).

Vitamin D level – Vitamin D deficiency has been associated with fatigue and treatment with vitamin D supplement significantly improved symptoms in a double-blind placebo-controlled trial (Nowak et al., 2016). Therefore, it is crucial that this is assessed to identify the need for vitamin supplementation.

Drug Screening – Childhood depression increases the risk of developing substance-related disorders (Groenman et al., 2017). Since the patient had a prior history of Marijuana use, it is important to test for other illicit drug use.

Lipid Panel – Due to the family history of hypertension and obesity. Furthermore, the patient’s sedentary lifestyle with consumption of foods high in fat increases the risk of cardiovascular disease.

3.      Health Promotion (Anticipatory Guidance)

• Visit the dentist at least twice a
• Brush your teeth at least twice a day and floss once a day.
• Wear your mouth guard when playing
• Protect your hearing at work, home, and
• Try to eat healthy
• 5 fruits and vegetables a day
• 3 cups of low-fat milk, yogurt, or cheese
• Eating breakfast is very
• Drink plenty of Choose water instead of soda.
• Eat with your family
• Aim for 1 hour of vigorous physical activity every
• Try to limit watching TV, playing video games, or playing on the computer to 2 hours a day (outside of homework time).
• Be proud of yourself when you do something good.
• Talk with your parents about your values and expectations for drinking, drug use, tobacco use, driving, and
• Talk with your parents when you need support or help in making healthy decisions about
• Find safe activities at school and in the
• Make healthy decisions about sex, tobacco, alcohol, and other drugs.
• Follow your family’s
• Do not drink and drive or ride in a vehicle with someone who has been using drugs or
• If you feel unsafe driving or riding with someone, call someone you trust to drive
• Support friends who choose not to use tobacco, alcohol, drugs, steroids, or diet pills.
• Insist that seat belts be used by • Always be a safe and cautious driver.
• Limit the number of friends in the car, nighttime driving, and
• Never allow physical harm of yourself or others at home or
• Learn how to deal with conflict without using
• Understand that healthy dating relationships are built on respect and that saying “no” is
• Fighting and carrying weapons can be
• Talk with your parents about your hopes and
• Figure out healthy ways to deal with
• Look for ways you can help out at home.
• Develop ways to solve problems and make good
• It’s important for you to have accurate information about sexuality, your physical development, and your sexual Please ask me if you have any questions.
• Set high goals for yourself in school, your future, and other
• Read
• Ask for help when you need
• Find new activities you
• Consider volunteering and helping others in

the community with an issue that interests or concerns you.

• Be a part of positive after-school activities and sports.
• Form healthy friendships and find fun, safe things to do with
• Spend time with your family and help at
• Take responsibility for getting your homework done and getting to school or work on (BrightFutures, 2019)

4.      Patient Education

Educate the patient and parent that it takes four to six weeks of starting an antidepressant medication to see its maximum response and doses can be adjusted to improve response every two to four weeks as long as significant side effects are absent. Explain that elevated energy can occur due to the medications. Therefore, it is crucial that parents report symptoms that merit immediate evaluation such as decreased impulse control, marked elevation of mood, acting out, fearlessness, and risk taking. Report immediately if the child expresses suicidal ideations or behaviors. Ensure that the child has no access to weapons or medications or any other means of self-harm and have constant supervision during treatment.

Explain to the patient to follow mediation regimen as instructed and never abruptly discontinue as it may result in adverse effects such as nausea, sweating, dysphoric mood, irritability, agitation, dizziness, sensory disturbances, confusion, headache, lethargy, emotional lability, insomnia, hypomania, tinnitus, and seizures.

Avoid alcohol while taking antidepressants. There is correlation of alcohol dependence and major depression thus two conditions may have a causal effect with each disorder increasing the risk of developing the other (Kuria et al., 2012).

5.      Consult

Consult pediatric mental health therapist for psychotherapy, cognitive-behavior therapy, and patient-family counseling.

Refer to community support groups for children and families experiencing depression

6.      Disposition

Follow up by phone within three days of starting pharmacotherapy and have the patient come back in the clinic weekly for four weeks to evaluate response to therapy. Once stable, may have maintenance visits every three months. If no improvement within two months of starting SSRI, reassess the need for hospitalization if in immediate danger.