NURS 680A Advanced Health/Physical Assessment Week 2 Discussion Forum

A 52-year-old woman complains that she has been missing days of work almost every week, she states she is neglecting her family, and she is sleeping during the day but cannot sleep at night. She denies other health problems, medication, or environmental allergies.

Discuss what questions you would ask the patient, what physical exam elements you would include, and what further testing you would want to have performed.
In SOAP format, list:
- Pertinent positive and negative information
- Differential and working diagnosis
- Treatment plan, including: pharmacotherapy with complementary and OTC therapy, diagnostics (labs and testing), health education and lifestyle changes, age-appropriate preventive care, and follow-up to this visit.
Use at least one scholarly source other than your textbook to connect your response to national guidelines and evidence-based research in support of your ideas.

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Sample Solution

Due to her self-reported insomnia, family neglect, and erratic attendance at work, this 52-year-old woman exhibits symptoms that are similar to depression or a depressive episode. Extrapolating conclusions based on the scant data does point to the presence of exhaustion, impaired focus, reduced interests, and low mood. These last three are all recognized as signs of serious depression and must last for more than two weeks as well as entail a loss of interest (American Psychiatric Association, 2017). However, according to the case study data the length of time of these symptoms is unknown.

In the absence of pertinent medical history, family history, allergies, or medications I would begin with using the OLDCART method to ascertain the severity, degree, and duration of her symptoms to establish a timeline and progression (Jarvis et al., 2020). Based on the DSM-5 criteria, I would continue to ask questions to assess her mood, previous and current activities and interests, current state of her diet and appetite, emotional state and feeling of self, acute or chronic pain, and a suicidal ideation assessment (American Psychiatric Association, 2017).

As it is clear her mental status is abnormal, prior to making any determinations based on subjective data alone, a physical assessment is in order. I would proceed to assess pupillary function via flashlight to gauge on response, cardiopulmonary-gastrointestinal auscultation to assess for abnormal lung sounds, heart sounds, or bowel sounds paired with a visual-tactile assessment for any integumentary abnormalities. The palpation of lymph nodes would also be included, as well as a neuromuscular assessment.

Current symptoms considered, it is difficult to determine if this is not depression caused by another physiological process, therefore it is necessary to conduct lab work that may contribute to elucidating the cause of the symptoms. As recommended by Bains and Abdijadid (2021) it is necessary to assess thyroid function via TSH testing, vitamin D levels, a CBC and iron levels to assess for anemia, and a CMP to assess for other possible metabolic abnormalities, all of which can be causal of depression in-situ.

Pertinent Data

The patient is reporting insomnia, missing work days, neglecting family, and fatigue during the day. The latter are all pertinent positives towards a diagnosis of depression. Pertinent negatives include the absence of any other physical symptoms, and suggest no acute physiological involvement. Pending additional workup in terms of lab work, there are no additional pertinent negative or positives.

The working diagnosis will be set to major depression based on current symptoms (American Psychiatric Association, 2017), with differential diagnoses set to be anxiety, vitamin D deficiency, thyroid dysfunction, and anemia (Bains & Abdijadid, 2021) pending lab work for rule out.

Treatment plan will include the need for the aforementioned further testing in terms of CBC, CMP, TSH, and vitamin D levels. Immediate recommendation is the initiation of cognitive behavioral therapy to assist in improving mood, self-regard, and setting new routines. I would also recommend light forms of physical exercise, a healthy diet, and a follow in two weeks to assess progression and augment the treatment plan per lab results and/or recommendation from the DSM-5 (American Psychiatric Association, 2017).

References:

American Psychiatric Association. (2017). Diagnostic and statistical manual of mental disorders: Dsm-5.
Bains, N. & Abdijadid, S. (2021). Major Depressive Disorder. National Library of Medicine,
StatPearls. StatPearls Publishing, Treasure Island, Florida.
Jarvis, C., Eckhardt, A., & Thomas, P. (2020). Physical Examination & Health Assessment. Elsevier.

NURS 680A Advanced Health/Physical Assessment Week 2 Discussion Forum