NR602 Week 6 iHuman Angela Cortez Behavioral Health

NR602 Week 6 iHuman Angela Cortez Behavioral Health

iHuman Screenshots included in this document Angela Cortez

17f
5’4” (163 cm)
168 lb (76.4 kg) previous weight 142 (64.5 kg)

Reason for Encounter: Fatigue

Good Questions

How can I help you today? My mom made me come here because I’m tired all the time (eyes are tearful, slightly annoyed tone of voice).
Do you have any other symptoms or concerns we should discuss? I don’t think I have any symptoms….I’m just here because of my mother.
When did your fatigue/tiredness start? I don’t know, maybe about two months or so ago?
What are the events surrounding the start of your fatigue/tiredness? I don’t know (eyes are tearful). Maybe I just feel a lot of pressure because it’s my senior year. They lay on a lot of pressure, you know?
Does your fatigue/tiredness improve after a good night’s rest? I think I get enough sleep, but I still wake up tired. It doesn’t seem to matter. I’m always tired.
Have you been feeling sad, depressed, or hopeless? If so, how often do you feel this way? No….well, I feel like I can’t do anything right - school isn’t fun anymore, just doesn’t seem worth it most of the time. I get so upset and frustrated, I’m crying every day! I do find my parents irritating and they are always on my case (eyes are tearful).
Have you been nervous, anxious, or worried about something? Yeah. Especially about college….I know that if I don’t get into college with a scholarship, then my parents will think that I’m worthless (starts crying). And there’s no way I’ll get in with how things are going so far this year.
Are you crying more than usual? Yeah…..I cried daily after I lost my boyfriend, but that was months ago and I’m over it! I don’t really understand why I started crying daily again, just this last month….but I’m really not thinking about him….I just find everybody annoying and so I start crying.
How are your grades in school? I just can’t focus on school as well as I used to. Last semester I had a 3.5 GPA. We’ve only had a few tests so far this fall and I got C’s on two of them. I just don’t care about my grades as much as I used to.
Are you having any difficulty sleeping? No!! Thank goodness, that’s the only time no one bothers me at home.
Do you blame yourself for everything wrong? Yes about my boyfriend, I’m not sure why he left me so that is probably my fault. But when it comes to my family, they are just on my case and I don’t understand it……I guess I have no one to blame but myself for my weight if that’s what you mean…..
Have you had any thoughts of hurting or killing yourself? No, I would never do anything stupid like that. But sometimes I wish I could just disappear and not have to deal with anything anymore.
Do you wish you were not alive anymore or fell asleep and didn’t wake up? If so, how often have you had these thoughts? On some school days, I wish I could just disappear and hide from the world…..
Have you gained or lost weight unintentionally, despite normal appetite and exercise? I’ve put on some weight, maybe 25-30 pounds or so since last year. I wasn’t trying to….I think it’s maybe just because I’m maturing as a woman…..or maybe because I stopped track, I don’t know. But now I’ve got these ugly stretch marks! Do you know what causes these?!?! I hate them!
Tell me about daily exercise or sports that you play. None really now. I used to be on the track team, but I didn’t try out. I just don’t have the energy…. (eyes are tearful).
How would you describe your moods? Well, my family says I’m “crabby” and they want to blame it on my periods. But I feel the same way all month long…..they just annoy me a lot, okay?
Do you find that it is hard to experience feelings like happiness, love, or satisfaction? I guess I might still be down from the breakup….
Have you lost interest in or avoided social activities? I don’t avoid social activities….well, maybe I do a little bit since my boyfriend had dumped me for one of my friends — we went to prom together. I haven’t dated anyone since then, and I don’t want to.
How is your appetite? Any recent change? Sort of. I feel hungry all the time….
Can you tell me about your diet? What do you normally eat? I skip breakfast because I have been gaining weight….the rest of my diet is about the same, I have pizza and maybe french fries for lunch two or three times a week and french fries as a snack on the way home. My mom cooks dinner, but by the time I am doing my homework at night, I am so tired that I need snacks to keep me going.
How is your family and family life? I have to share a room with my sister, who is a freshman. I can’t stand the way she is so excited about high school and the messes she makes in our room drive me inside! My sister and her friends are so annoying, too!! (crying) My mother’s constantly on me about spending too much time on the internet, rather than being “social” as she calls it. And she’s also on me about helping around the house. So, is that what you want to know?
Are there any guns in your home? If so, are they stored in a secure location? No guns.
Are you sexually active? I had sex a few times last year with my boyfriend. That’s over and I haven’t done it since.
Is it possible that you are pregnant? That’s what they all ask! I am not pregnant I’ve never been pregnant’ my periods are like clockwork; my last one was two weeks ago; and I certainly don’t have those symptoms they drill into your head in health. Besides I don’t have a boyfriend, okay?
Any new or recent change in medications? No, no prescription meds. Is that what you mean?
Are you taking any OTC or herbal medications? I take ibuprofen for menstrual cramps; they’re there with each period, but not that bad.
Do you drink alcohol? If so, what do you drink, and how many drinks per day? I only really drink beers at parties….well, maybe occasionally just with my friends. But it’s not a problem.
Has drinking alcohol ever caused you any problems? No, but it probably did if my mom knew I drank as much as I do.
Has anyone suggested that you should reduce the amount of alcohol you drink? No.
Do you feel guilty about the amount of alcohol you drink? Not at all.
Do you use any recreational drugs? If so, what? I tried marijuana once last year with my old boyfriend. Nothing else though.
Are your immunizations up to date? Yeah, they kind of have to be if I want to go to school.
Do you have any allergies? None that I know of.
Skin/hair/nails: Do you have any problems with itchy scalp, skin changes, moles, thinning hair, brittle nails? What do you mean by skin changes?
HEENT: Do you have any problems with headaches that do not go away with aspirin or Tylenol… No. Denies headaches. Denies double or blurred vision or difficulty seeing at night, and denies problems hearing or ear pain. Denies sinus problems, chronic sore throats, or difficulty swallowing.
Breast: Have you noticed any discharge from your breast, lumps, scaly nipples, pain or swelling, redness? No. Denies breast discharge, lumps, scaly nipples, pain, swelling, or redness.
Cardiac: Do you experience chest pain, discomfort, pressure, pain/pressure/dizziness with exertion or getting angry? No. Denies chest pain, discomfort, or pressure; denies any pain/pressure/dizziness with exertion or getting angry; denies palpitations, denies exercise intolerance, denies blue/cold fingers or toes.
Respiratory: Do you experience shortness of breath, wheezing, difficulty catching your breath, chronic cough, sputum production? No. Denies shortness of breath, wheezing, difficulty catching your breath, chronic cough, or sputum production.
GI: Do you have problems with nausea, vomiting, constipation, diarrhea, coffee grounds… No. Denies any nausea, vomiting, constipation, diarrhea, coffee grounds in vomit, dark tarry stool, bright red blood in bowel movements, denies any satiety or bloating.
Hemat: Have you noticed any bruising or bleeding gums or other sites… No.
Neuro: Do you have any of the following: dizziness, fainting, spinning room, seizures, weakness, numbness… No.
GU: When you urinate, have you noticed: pain, difficulty starting or stopping… No. Denies difficulty urinating, denies any pain, burning, blood, difficulty starting or stopping, dribbling, incontinence, urgency during day or night, denies any change in frequency.
Endocrine: Uh….I don’t think so. Denies any heat or cold intolerance, increased thirst or sweating, denies frequent urination, or change in appetite.
Not Good Questions
Have you been depressed? I don’t know.
Have you lost interest? Kinda.
Are you happy with your body image? Look at these stretch marks! How would you feel?
Do you feel like a failure? My mom probably thinks I’m a screw-up.
How much water? A normal amount.
Drink caffeinated or chocolate? No.
Where do you live? Right here in town.
Musculoskeletal: No. Denies any problems with muscle or joint pain, redness, swelling, muscle cramps, joint stiffness, joint swelling or redness, back pain, neck or shoulder pain, or hip pain.
General: Yes, fatigue….you know tired. That’s why my mom insisted I come here. What else did you ask about?

Physical Exam

Auscultate heart: Normal
Auscultate lungs: Normal
Visual chest: Chest is symmetrical, and the AP diameter is normal. The excursion with respiration is symmetrical, and there are no abnormal retractions or use of accessory muscles. No distention, scars, masses, or rashes.
Inspect eyes: Sclera anicteric, conjunctivae without injection, discharge, or pallor. No periorbital edema or trauma. Eyes are tearful.
Examine pupils: PERRL
Ocular motor: H-test normal
Ophthalmoscope: Red reflex bilaterally, optic disks sharp.
Inspect neck: No visible scars, deformities, or other lesions, trachea is midline and freely mobile.
Palpate neck: Supple, full ROM, thyroid WNL, no cervical lymphadenopathy.
Swallow: Normal, thyroid moves with swallowing.
Inspect ears: Normal appearing external structures, no deformities or edema, no discharge noted.
Look in ears: External auditory canals without erythema or cerumen. Tympanic membrane translucent, non-injected, and pinkish-gray in color. No scarring, discharge, or purulence noted. Landmarks visible.
Inspect skin: No signs of self-harm, mild comedonal acne on forehead, acanthosis nigricans at nape of neck, striae noted on abdomen and buttocks.
Inspect hair: Thickness and distribution pattern typical of patient gender and age.
Inspect mouth/pharynx: Oropharynx not injected, clear mucosa, tonsils without exudate, tongue pink, symmetrical, no swelling or ulcerations.
Inspect/palpate head: Normocephalic, atraumatic, no deformities. Facial features symmetric, temporal arteries non-tender to palpation, frontal and maxillary sinuses non-tender.
Inspect/palpate scalp: No visible scaliness, edema, masses, lumps, deformities, scars, rashes, nevi, or other lesions, non-tender.
Evaluate ROM: Full ROM.
Inspect nails: Nails without ridging, pitting, or peeling.
Visual extremities: No swelling or deformity, no cyanosis, clubbing, or edema.
Palpate extremities: No tenderness, muscular resistance, rigidity, or deformity.
Palpate lymph nodes: No pathologically enlarged lymph nodes in the cervical, supraclavicular, axillary, or inguinal chains.
Visual ABD: Mildly obese, scattered abdominal striae present, Tanner V pubic hair distribution.
Auscultate ABD: Bowel sounds active.
Palpate ABD: Soft, nondistended, no hepatomegaly or palpable mass, non-tender to kidney ballottement and flank percussion. Uterus nonpalpable; non-tender to suprapubic palpation, ABD otherwise non-tender throughout.
Percuss ABD: No tympany or shifting dullness.
Assess cranial nerves: II-XII intact.
Look for involuntary movement: None.
DTR: Normal.
Plantar/babinski: Normal.
Sensory tests: Light touch, pain, temperature, vibration, and proprioception are grossly intact.

Key Findings:

Fatigue for 2 months with decreased energy
Tearful, crying daily
Anhedonia (loss of interest in activities)
Sexually active
Unintentional weight gain of 25-30 pounds
Alcohol use
Marijuana use
BMI of 28.8
Abdominal and buttock striae
Decline in school grades, worried about college
Low self-esteem, feeling “worthless”
Acanthosis nigricans
Acne
Home life stress
Irritability
Poor diet

Differential Diagnosis:

Anemia
Depression
ADHD
Pregnancy
Cushing’s syndrome
Hypothyroidism
Infectious mononucleosis
Type 2 Diabetes
Substance/medication-induced mood disorder
Chronic fatigue syndrome

Case Findings:

Abdominal striae
Tearfulness
Anhedonia
Family history of Type 2 Diabetes/obesity
Decline in school grades
Weight gain
Acne
Elevated BMI
Fatigue
Acanthosis Nigricans
Irritability

Differential Diagnosis Considerations:

Anemia
ADHD
Cushing’s syndrome
Depression
Type 2 Diabetes
Hypothyroidism
Infectious mononucleosis
Pregnancy

Diagnostic Testing Ordered:

Complete blood count (CBC), blood
Cortisol, free, 24-hour urine
Free thyroxine (free T4), blood
Glucose, blood (BG)
Glycated hemoglobin (HbA1c), blood
Human chorionic gonadotropin (hCG), urine
Monospot, blood
Thyroid stimulating hormone (TSH), blood
Toxicology screen, urine

Not Required:

Adrenocorticotropic hormone (ACTH), blood
Basic metabolic panel (BMP), blood
Comprehensive metabolic panel (CMP), blood
Cortisol, AM
Cortisol, PM
Ferritin, blood
Free triiodothyronine (free T3), blood
Iron
Total iron-binding capacity (TIBC), blood
Toxicology screen, blood
Transferrin saturation (TSAT)
Transferrin, blood
Urinalysis (UA) Epstein-Barr virus (EBV) antibody, blood

Case Problem Statement:

AC is a 17-year-old female who presents to the office with complaints of fatigue/tiredness for 2 months.
Associated symptoms include frustration, irritability, anhedonia, decreased school performance, emotional lability, and unintentional 25-30 lb weight gain.
Physical exam notable for obesity, abdominal striae, acanthosis nigricans.
No significant past medical history.
Social history includes sexual activity, alcohol, and marijuana use.
She denies suicidal ideation or self-harm but reports wanting to “disappear.”

History of Present Illness:

AC is a 17-year-old female who presents to the office for increased fatigue and tiredness for 2 months.
Reports an increase in school stress due to the pressure of it being her senior year.
Reports she is frustrated, irritable, and cries daily.
Reports her grades have suffered immensely because of the stress.
Reports a recent breakup with her boyfriend, and she is still upset about it.
Reports an unintentional weight gain of 25-30 lbs, and her diet consists of pizza and french fries; she often skips breakfast.
Reports feeling like she “can’t do anything right anymore.”
Reports feeling frustrated and is crying daily.
Reports previous sexual activity and use of alcohol and marijuana.

Physical Examination

BMI: 28.8
A&O x4
Temperature: 37°C / 98.6°F
Pulse: 70 bpm, regular, normal
Blood Pressure: Left: 110/74, Right: 110/72, normotensive, normal
Respiratory Rate: 14 bpm, regular, unlabored
Oxygen Saturation: 99%
Patient is reluctant to make eye contact
Skin: Warm, dry, no signs of self-harm (e.g., picking, cutting, burning), mild comedonal acne on forehead, acanthosis nigricans at nape of neck, striae noted on abdomen and buttocks.
Inspect scalp/head: No visible scaliness, edema, masses, lumps, deformities, scars, rashes, nevi, or other lesions, non-tender. Head is normocephalic, atraumatic, no deformities. Facial features are symmetric. Temporal arteries non-tender to palpation. Frontal and maxillary sinuses non-tender.
Eyes: Sclera anicteric, conjunctivae without injection, discharge, or pallor, no periorbital edema or trauma, eyes are tearful. PERRLA.
Mouth: Oropharynx not injected, clear mucosa, tonsils without exudate. Tongue pink, symmetrical. No swelling or ulcerations.
Neck: No visible scars, deformities, or other lesions. Trachea is midline and freely mobile. Neck supple, full range of motion. Thyroid WNL, no cervical lymphadenopathy.
Chest: Chest is symmetrical and the anterior-posterior (AP) diameter is normal. The excursion with respiration is symmetrical and there are no abnormal retractions or use of accessory muscles. No distension, scars, masses, or rashes. No tenderness. Lung sounds are clear bilaterally, anterior and posterior.
Heart: PMI quarter-sized, brisk, and tapping in the 5th intercostal space at the midclavicular line. Heart sounds are normal, S1/S2 heard. No murmurs, gallops, or clicks heard.
Abdomen: Mildly obese, scattered abdominal striae present, Tanner V pubic-hair distribution, normo-active bowel sounds, soft, non-distended, no hepatomegaly or palpable mass, non-tender to kidney ballottement and flank percussion, uterus non-palpable; non-tender to suprapubic palpation, abdomen otherwise non-tender throughout.
Musculoskeletal: Normal bulk and tone, no rigidity, no edema, bruising, or deformity to extremities. No cyanosis or clubbing.
Lymph: No lymphadenopathy.
Neurologic: Cranial nerves II-XII intact.
GU: Normal external genitalia. No signs of vulvar infection or trauma, striae noted on buttocks, bimanual deferred.

EHR Record

PMH:

Croup at age 2, fracture of the right wrist due to a rollerblading accident at age 11.

Hospitalizations:

None

Medications:

Occasional ibuprofen for menstrual cramps

Allergies:

None

Preventative Health:

Learning to drive, but says she knows better than to text and drive. Gets regular dental and annual wellness evaluations.

Immunizations:

Up-to-date

Family History:

Father: mild HTN, obesity
Mother: obesity
Positive family history for type 2 DM (maternal grandmother and aunt)

Social History:

Status: College-bound, high school junior, lives with parents and two siblings, a brother (10) & sister (14).
Denies: Tobacco use, alcohol consumption, marijuana use, illicit use, sexual activity.

HPI:

The patient is a 17-year-old female who presents to the office because “my mom made me come here because I’m tired all the time (eyes are tearful, slightly annoyed voice).” During the history intake, the patient reports fears of not making it into college because of difficulties concentrating on school work, making poor grades, and reports she had a recent breakup with her boyfriend last year but states “I’m over it now.” She reports concerns about being the reason for the breakup and reports crying every day since, but that she is not crying specifically due to the breakup. Reports an increase in weight gain of about 25-30 pounds. Denies suicidal thoughts or self-harm but does report she wishes she could disappear to escape the burden she feels from trying to please her family.

General:

Reports fatigue and weight gain. Denies difficulty sleeping, unintentional weight loss, fevers, or night sweats.

HEENT/Neck:

Denies double or blurred vision or difficulty seeing at night, and denies problems hearing or ear pain. Denies sinus problems, chronic sore throats, or difficulty swallowing.

Cardiovascular:

Denies chest pain, discomfort, or pressure; denies any pain/pressure/dizziness with exertion or getting angry; denies palpitations, denies exercise intolerance, denies blue/cold fingers or toes.

Respiratory:

Denies shortness of breath, wheezing, difficulty catching breath, chronic cough, or sputum production.

GI:

Denies any nausea, vomiting, constipation, diarrhea, coffee grounds in vomit, dark tarry stool, bright red blood in bowel movements, denies any satiety or bloating.

GU:

Denies difficulty urinating, denies any pain, burning, blood, difficulty starting or stopping, dribbling, incontinence, urgency during day or night, denies any change in frequency.

Musc/Osteo:

Denies any problems with muscle or joint pain, redness, swelling, muscle cramps, joint stiffness, joint swelling or redness, back pain, neck or shoulder pain, or hip pain.

Neuro:

Denies any dizziness, fainting, spinning room, seizures, weakness, or numbness.

Integ:

Denies breast discharge, lumps, scaly nipples, pain, swelling, or redness.

Psych:

Reports irritability, emotional lability, and frustration.

Endocrine:

Denies any heat or cold intolerance, increased thirst or sweating, denies frequent urination, or change in appetite.

Hemat:

Denies any bruising, bleeding gums, nose bleeds, or other sites of increased bleeding.

Allergic:

None

Management Plan

Diagnostic Test:

CBC: Normal, no evidence of anemia
Cortisol 24hr: Normal
Free T4: Normal
BG: Normal
A1c: Normal
HCG: Negative
Mono: Negative
TSH: Normal
Toxicology: Negative

Medication:

Fluoxetine (Prozac) 10 mg
- Take 1 capsule by mouth daily
- Dispense: 30
- Refills: 0
Teen Complete Gummy Multivitamin
- Take 1 gummy daily

Consults/Referrals:

Psychological therapy, such as cognitive-behavioral therapy
Psychiatrist
Nutritionist

Client Education:

Fluoxetine is a selective serotonin reuptake inhibitor (SSRI). Some common side effects you may experience are nausea, loss of appetite, diarrhea, headaches, dry mouth, constipation, tremors, or anxiety.
You may start to see improvements in your depression in a few weeks; however, it is imperative that you continue to take your medication exactly as prescribed.
Educated on the effects of alcohol and marijuana use.
Diet and exercise goals to encourage a healthy lifestyle and reduce BMI.
Educated on worsening signs and symptoms of depression and when to alert a healthcare professional. Mother aware of signs and symptoms to monitor for.
If at any time you experience any emotional distress, have thoughts of self-harm, suicidal behaviors, or thoughts, please report to the nearest emergency department for further evaluation. You may also contact the 988 Suicide & Crisis Lifeline 24/7, 365 days a year; the call is free and confidential.
Safety plan established, family aware.

Follow-up:

Follow up in 1 week and then again in 4 weeks for a medication check. It is likely the dose of your medication will increase. The goal is to slowly titrate your medication up to a therapeutic dose without any side effects.

References:

American Psychological Associates. (2019). APA clinical practice guideline for the treatment of depression across three age cohorts. https://www.apa.org/depression-guideline/guideline.pdf

NR602 Week 6 iHuman Angela Cortez Behavioral Health

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