please respond to these two discussions

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Please respond to these two discussions. Please provide intext references

  • 1) Discussion posted by Rosa:

    • Have you experienced any weight loss or gain?

    Any family history of depression?

    Do you experience any sleep disruption?

    Have you had any thoughts of harming, hurting or killing yourself?

    Have you been overeating?

    How is you academic performance?

    How are your relationships with your peers?

    Any change on physical activity?

    Have you had any traumatic event like a major accident, physical or sexual abuse?

    Several risks factors are interconnected and related to an increased risk of depression some are physical like being diagnosed with conditions such as asthma or diabetes mellitus during childhood, others are environmental such as peer relationships, school performance and some are biologic like having a parent that has been diagnosed with depression ( Clark et al., 2012).

  • Describe the clinical findings that may be present in a patient with this issue.

    • The clinical presentation include: having a depressed mood nearly every day, diminished interest in daily activities, weight loss or weight gain, being slowed down or increased restlessness, feelings of worthlessness, and thoughts of death or recurrent suicidal ideation ( Clark et al., 2012).

  • Are there any diagnostic studies that should be ordered on this patient? Why?

    • It is important to consider ordering thyroid studies: TSH, free T4, Hemoglobin and hematocrit, mono spot test.

  • List the primary diagnosis and three differential diagnoses for this patient. Explain your reasoning for each.

    • Primary Diagnosis: Depression

    Hypothyroidism

    Cushings Disease

    Anemia

    Fatigue is a common symptom associated with the previous diagnoses. An elevated serum TSH will suggest hypothyroidism associated symptoms would include weight gain and constipation. Cushings disease will be confirmed with an elevated 24 hour urinary free cortisol level, and anemia will be suggested if there is a decreased level of hemoglobin and hematocrit ( Clark et al., 2012).

  • Discuss your management plan for this patient, including pharmacologic therapies, tests, patient education, referrals, and follow-ups.

    • Cognitive Behavior Therapy (CBT) is highly recommended and should be used in addition to pharmacologic treatment. The American Psychiatric Association and the American Academy of Child and Adolescent Psychiatry (2018) recommend that : psychotherapy should be used as an option for patients with milder depression, and a combination of medication and psychotherapy in those with moderate to severe depression.

    It is also recommended that fluoxetine and lexapro can be used as effective therapy for adolescents, treatment should always begin at the lowest dosage available and titrated accordingly to symptoms (Hetrick et al., 2007).

    Education: It is important to educate the patient on increase exercise, increase water intake and to keep a balanced diet, decrease refined sugars like soda, and discuss sleep hygiene habits.

    The patient should be followed up at least 30 days after initiation of therapy and as needed ( Clark et al., 2012).

    References:

    American Psychiatric Association, American Academy of Child and Adolescent Psychiatry (2018). The use of medication in treating childhood and adolescent depression: information for patients and families. http://www.parentsmedguide.org/parentsmedguide.pdf. Accessed November 12, 2018.

    Hetrick S, Merry S, McKenzie J, Sindahl P, Proctor M. (2007). Selective serotonin reuptake inhibitors (SSRIs) for depressive disorders in children and adolescents Cochrane Database Syst Rev. (3):CD004851.

    Clark, M., Jansen, K., Cloy, A., (2012). Treatment of Childhood and Adoslecent Depression. Am Fam Physician. 2012 Sep 1;86(5):442-44





  • 2) Discussion written by Lauri2) Discussion written by Lauri2) Discussion written by Lauri




    2) Discussion written by LauriDiscuss the questions that would be important to include when interviewing a patient with this issue.Questions should assist with narrowing down and ruling out differentials. Determining major depressive disorder will rely on a solid history and ruling out differentials as there is no specific test for depression (Orlander, 2018).
  • Answer:
    1. What brings you in today?
    2. How long have you felt poorly?
    3. Is your living situation safe? Any violence or abuse?
    4. Are you active?
    5. What do you enjoy?’
    6. Do you feel emotional? Angry? Sad? Happy? Tearful?
    7. Participating in social activities?
    8. Energy level?
    9. How are you sleeping?
    10. Are you hot or cold frequently?
    11. How is your appetite?
    12. Are you happy with how you look?
    13. Are you satisfied with where you are in life?
    14. Anxiety? Depression?
    15. Drugs? Alcohol? Tobacco?
    16. Is there an event that you recall triggering your feelings?

    Describe the clinical findings that may be present in a patient with this issueWith depression, the patient my express or display feelings of sadness, hopelessness or irritability; changes in eating patterns; changes in sleeping patterns; not enjoying or wanting to participate in activities; changes in energy level; concentration issues; feeling unworthy or guilty or thinking about or injuring self are all signs of depression (CDC, 2018). Are there any diagnostic studies that should be ordered on this patient? Why?Before making the diagnosis of depression, all testing should be exhausted to rule out medical causes including drug testing. There are some very odd autoimmune diseases that could require a specialist to evaluate to be sure there is not something else. I would accept the current lab values and then move to treating with Fluoxetine and reevaluating for response. List the primary diagnosis and three differential diagnoses for this patient. Explain your reasoning for each.The primary diagnosis for this exercise was major depressive disorder by exclusion of other diseases. The patient clearly is suffering from apathy and lack of interest or joy. Depression is a common and serious mood disorder with various levels of severity (NIMH, 2018). “Depression is caused by a combination of genetic, biological, environmental, and psychological factors” (NIMH, 2018). With the prevalence of depression and current results of labs, we diagnose depression since there is nothing else the patient fits.Differential Diagnosis:1. Hypothyroid – Hypothyroidism is the most common thyroid disorder in babies, kids and teens according to Dr. Bauer, medical director of The Thyroid Center at Children’s Hospital of Philadelphia (Harrar & Bauer, 2017). “Girls are 4 times more likely to develop it then boys and early diagnosis and treatment is crucial to ensure normal physical development and normal brain development” (Harrar & Bauer, 2017, p. np). Diagnosis in teens if frequently missed and the patient is diagnosed with ADHD or behavior issues instead (Harrar & Bauer, 2017). Hypothyroidism can cause severe fatigue, weight gain, depression, periorbital puffiness, hair loss, dry skin, menstrual changes, emotional lability to name a few symptoms (Orlander, 2018). The patient’s lab work does not support this.2. Cushing’s Disease: Cushing’s disease is caused by elevated levels of cortisol causing weight gain, especially around the face and trunk by either a issue with the pituitary gland and ACTH, an adrenal tumor or induced by pharmacology (Surgeons, 2018). There is no single symptom shared by all kids with Cushing’s disease, the only real consistent finding is weight gain; however other symptoms may include headache, irritability, amenorrhea or dysmenorrhea, sleep disturbances and hypertension (Keil, 2018). A 24-hour urine cortisol, salivary cortisol levels and/or low dose dexamethasone suppression test at night with morning cortisol levels can help assess and diagnose this in conjunction with clinical evaluation and imaging of the pituitary and adrenals (Keil, 2018). The patient’s lab work does not support this either. 3. Anemia: The American Society of Hematology has identified many types of anemia. Anemia is the deficiency of red blood cells or the dysfunction of the red blood cells (Hematology, 2018). This dysfunction leads to a deficiency in oxygen leading to fatigue, shortness of breath, pain, weakness, coldness (Hematology, 2018). Anemia can also be due to vitamin B-12 or folate deficiencies or inability to absorb too. Assessing GI function and proper nutritional status is an important part of caring for this patient (Hematology, 2018). Discuss your management plan for this patient, including pharmacologic therapies, tests, patient education, referrals, and follow-ups.1.Initially, after all medical differentials ruled out satisfactorily, I would start the patient on a selective serotonin reuptake inhibitor to treat her depression. I would choose Lexapro 10 mg po q d due to the lesser side effects (Gautam, Jain, Gautam, Vahia, & Grover, 2017). Education on this medication would need to be simple due to her comprehension and include open communication regarding suicidal thoughts and worsening depression. Side effects such as dizziness, constipation, nausea and headache would be discussed.2. Patient should be referred for psychiatric therapy should be set up to support the patient working through her issues.3. Patient needs a regular exercise program to help with weight and personal confidence. I would consider a program with a nutritionist and support group as well.4. Follow up in 4 weeks to evaluate progress.ReferencesCDC. (2018, Nov 11). Retrieved from CDC Children’s mental health: https://www.cdc.gov/childrensmentalhealth/depression.htmlGautam, S., Jain, A., Gautam, M., Vahia, V., & Grover, S. (2017). Clinical practice guidelines for the management of depression. Indian Journal Psychiatry, S34-S50.Harrar, S., & Bauer, A. J. (2017, Jan 19). Endocrineweb. Retrieved from endocrineweb: https://www.endocrineweb.com/conditions/hypothyroidism/5-surprising-facts-about-low-thyroid-children-teensHematology, A. S. (2018, Nov 11). hematology.org. Retrieved from hematology .org: http://www.hematology.org/Patients/Anemia/#a3Keil, M. (2018, Winter 2004). Cushing support and research foundation CSRF. Retrieved from CSRG: https://csrf.net/understanding-cushings/pediatric-cushings/cushings-syndrome-in-children/NIMH, N. I. (2018, Nov 11). nimh. Retrieved from nimh.NIH.gov: https://www.nimh.nih.gov/health/topics/depression/index.shtmlOrlander, P. (2018, Feb 25). Medscape. Retrieved from Medscape: https://emedicine.medscape.com/article/122393-overviewSurgeons, A. A. (2018, Nov 11). AANS. Retrieved from AANS.org: htt

  • Additional questions to ask during the interview should be directed towards ruling out other conditions. The symptoms from this case study are suggested of three different conditions: major depressive disorder, hypothyroidism, and Cushing syndrome. One of the questions is whether she has noticed any changes in her menstrual cycle since Cushing syndrome is associated with amenorrhea. Proximal muscle weakness should also be inquired by questions related to difficulty climbing stairs or raising from a squatting position. Other questions include difficult in wound healing, osteopenia, frequent infections, and history of fractures (Vance, 2017). Symptoms suggestive of increased intracranial pressure due to ACTH-secreting tumors should be explored, and this includes headaches, blurred visions, and vomiting. Clinical FeaturesPhysical examination in this patient are protean, and it depends on the system affected. General examination can reveal moon facies, buffalo hump and fat pads in the supraclavicular region. In addition, central obesity may be present due to the accumulation of fat in the mediastinum and peritoneum. Hirsutism and male pattern balding can also be evident. Physical findings in the cardio-renal system may demonstrate hypertension and edema due to cortisol-induced activation of mineralocorticoid receptors which leads to accumulation of sodium and water in the body (Vance, 2017). Galactorrhea may also be evident since Cushing syndrome can be caused by anterior pituitary tumors which exerts pressures on the pituitary stalk leading increased levels of prolactin. Proximal muscle weakness and diminished tendon reflexes are also some of the clinical findings may be found in patients with Cushing syndrome. Diagnostic TestsDiagnostic tests for this patient are diverse and range laboratory and imaging studies. One of the most significant laboratory tests is serum or urinary cortisol which should be high for a positive diagnosis of Cushing syndrome. Other tests that are acceptable include dexamethasone suppression test, urinary free cortisol and evening salivary cortisol levels. Another important laboratory test is a dexamethasone-corticotropin test to rule out other conditions that can mimic Cushing syndrome. Serum T3 and T 4 should also be assayed since some if the clinical features are also suggestive of hypothyroidism. Imaging studies should come second to biochemical evaluation to avoid being misled by non-functional pituitary adenomas. Imaging studies for suspected pituitary pathology should be contrast-enhanced MRI of the brain. In cases where adrenal pathology is likely to be the case, an abdominal CT scan should be performed. A CT scan of the chest can detect ectopic ACTH production.Primary and Differential DiagnosisPrimary Diagnosis From the case study, the clinical features are highly suggestive of Cushing syndrome. Patients with increased weight gain and skin changes such as acne, striae, and acanthosis body (Vance, 2017). These are typical symptoms of Cushing syndrome. The patient having symptoms of depression can be as a result of Cushing syndrome (Cosci, Fava, & Sonino, 2015). Elevated levels of cortisol hormone are associated with neuropsychological effects which include low mood, fatigue, and emotional liability. Differential Diagnosis
    1. Hypothyroidism due to increased weight as shown been elevated BMI and symptoms of depression such as fatigue, low energy, and lack of interest in previously pleasurable activities.
    2. Major depressive disorder. The patient has clinical features that are suggestive of major depressive disorder such as low energy, fatigue apathy, associability, and anhedonia.
    3. Type 2 diabetes owing to elevated BMI and skin changes such as acanthosis and striae due to insulin resistance. Cushing syndrome can also lead to Hyperinsulinism.

    Management PlanApproach consideration can either be pharmacological or surgical. Pharmacological intervention in Cushing syndrome includes octreotide, adrenal steroid inhibitors such as ketoconazole and antagonist against glucocorticoids such as mifepristone. Surgical intervention encompasses removal of ACTH producing a tumour. The patient should be referred to a neurosurgeon and followed up by an experienced endocrinologist. The levels of serum cortisol should be measured during each follow-up to assess the effectiveness of the interventions. ReferencesCosci, F., Fava, G. A., & Sonino, N. (2015). Mood and anxiety disorders as early manifestations of medical illness: a systematic review. Psychotherapy and psychosomatics, 84(1), 22-29.Vance, M. L. (2017). Physical Presentation of Cushing’s Syndrome: Typical and Atypical Presentations. In Cushing’s Disease (pp. 57-65).





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