Subjective:

• Chief Complaint (CC): Fatigue
• History of Present Illness (HPI): C.P is a 31-year-old Hispanic female who presents with complaints of fatigue over the past three months. She reports a lack of energy and a loss of interest in activities she previously enjoyed. Despite having a stressful job as a sales executive, she had always managed to meet the demands of her role. Recently, however, she has been feeling increasingly tired, unable to concentrate at work, and withdrawn from social interactions. She also reports feelings of worthlessness and shame due to her perceived inability to meet her usual high standards. She has gained weight, which she attributes to eating excessively while at home, staying in bed, and watching television. She denies any previous treatment for mental health issues and has no history of suicidal thoughts.
• Past Medical History (PMHx):
  • No major illnesses.
  • Childhood illnesses: Chickenpox.
  • Chronic illnesses: None.
  • Surgeries: Appendectomy.
  • Hospitalizations: None except for appendectomy.
• Social History:
  • Patient is single and works as a company executive at a multinational company.
  • Previously enjoyed staying fit through walking, working out, and eating healthy, but has struggled with these activities recently.
  • Denies alcohol use and has never smoked.
• Family History:
  • Father: Deceased at 61 due to stroke complications.
  • Mother: Bipolar disorder.
  • Brother: Depression.
• Allergies: NKDA
• Current Medications: Daily multivitamin.

Review of Systems (ROS):

• General: Denies fever and chills. Reports weight gain and knee pain/stiffness.
• HEENT: Denies headaches, blurry vision, dizziness, ear pain, or nasal discharge.
• Integumentary: Denies bruising or recent changes. Reports mild swelling in the right knee.
• Lymphatics: Denies enlarged lymph nodes.
• Lungs: Denies shortness of breath, cough, or wheezing.
• Cardiovascular: Denies chest pain or palpitations.
• Musculoskeletal: Reports pain and stiffness in the right knee.

Objective:

• Vital Signs: BP 130/78, P 70, Resp 16, Sao2 98%.
• Height: 5'4"
• Weight: 182 pounds
• BMI: 31.24 (Obesity)
• Pain: 5/10 (Right knee)
• General Appearance:
  • The patient is a Caucasian female who appears her stated age.
  • She has an antalgic gait.
  • She is alert, oriented, and cooperative.
• Skin:
  • Right knee: Skin is cool, dry, and intact.
  • Skin color is normal for ethnicity, with no cyanosis or pallor.

Assessment:

Primary Diagnosis:

1. Major Depressive Disorder (MDD) (ICD-10: F32.9)
   • Rationale: The patient presents with symptoms indicative of MDD, including fatigue, loss of interest in activities, feelings of worthlessness, weight gain, and decreased concentration. The presence of a family history of depression and bipolar disorder further supports this diagnosis.

Differential Diagnoses:

1. Generalized Anxiety Disorder (GAD) (ICD-10: F41.1)
   • Rationale: Although the patient reports significant stress related to her job and feelings of worthlessness, the absence of pervasive worry and anxiety symptoms over various domains makes GAD less likely compared to MDD.
2. Hypothyroidism (ICD-10: E03.9)
   • Rationale: Hypothyroidism can present with fatigue, weight gain, and depressive symptoms. Given the patient’s complaints and family history of thyroid issues (mother with hypothyroidism), this condition should be considered.
3. Knee Osteoarthritis (ICD-10: M17.11)
   • Rationale: The patient reports pain and stiffness in the right knee, which may be indicative of osteoarthritis, especially given her BMI, which places additional stress on the joints.

Diagnostic Testing:

1. Comprehensive Metabolic Panel (CMP): To rule out any underlying metabolic issues contributing to the patient’s fatigue and weight gain.
2. Thyroid Function Tests (TSH, Free T4): To evaluate for hypothyroidism as a potential cause of her symptoms.
3. Complete Blood Count (CBC): To assess for anemia or other hematologic conditions that could be contributing to fatigue.
4. PHQ-9 (Patient Health Questionnaire-9): A screening tool for depression to assess the severity of depressive symptoms.
5. Knee X-ray: To evaluate the right knee pain and assess for osteoarthritis or other structural abnormalities.

Plan:

• Medications:
  • Initiate a selective serotonin reuptake inhibitor (SSRI) such as sertraline 50 mg daily for depression.
  • Consider prescribing an NSAID for knee pain if osteoarthritis is confirmed.
• Lifestyle Modifications:
  • Encourage a balanced diet and regular physical activity to manage weight.
  • Recommend cognitive behavioral therapy (CBT) for managing depressive symptoms.
• Referrals:
  • Referral to a mental health specialist for further evaluation and management of depression.
  • Referral to an orthopedic specialist if knee pain persists or worsens.
• Follow-Up:
  • Schedule a follow-up visit in 2-4 weeks to assess the effectiveness of treatment and make any necessary adjustments.
  • Monitor mood, energy levels, and any side effects from medications.

Education:

• Discuss the importance of adherence to prescribed medications and attending therapy sessions.
• Educate the patient on the potential side effects of SSRIs and the importance of gradual titration.
• Emphasize the importance of a support system, including involving family members in her care.

Outcome Goals:

• Improvement in mood, energy levels, and overall functioning.
• Reduction in knee pain and improvement in mobility.
• Achieve a BMI within the normal range through lifestyle changes.

References:

• American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
• National Institute for Health and Care Excellence (NICE). (2019). Depression in adults: recognition and management.