CC (chief complaint): The patient experiences apathy, loss of interest in what is happening around her, and she no longer enjoys anything.
HPI: A 28-year-old Asian woman presents for psychiatric evaluation for apathy and suicidal thoughts. She is currently prescribed Mirtazapine.
The patient has a depressed mood, impaired activity, decreased interest in life, insomnia or hypersomnia, psychomotor retardation, fatigue, recurrent thoughts of suicide, low self-esteem, impaired concentration, and difficulty in making decisions.
Past Psychiatric History
General Statement: The patient was treated by a private psychiatrist who prescribed appropriate medications. However, the appointments did not have a positive effect, and the patient stopped visiting a psychiatrist two months ago.
Caregivers: The patient was not constantly monitored and did not establish medical care. She was not in inpatient care.
Hospitalizations: She was not hospitalized and had no diagnosed mental or physical health problems.
Medication trials: No tests were performed, no explanation was provided for prescribing antidepressants, no tracking of the medication’s effectiveness was performed.
Psychotherapy or Previous Psychiatric Diagnosis: No official diagnosis exists for the patient. At the same time, the patient did not consider the therapy useful and was dissatisfied with the doctor’s work. Hyperkinesis manifested by trembling of the hands is a neurological disorder.
Substance Current Use History: The patient does not use any addictive substances.
Family Psychiatric/Substance Use History: There are no known drug use or alcohol abuse cases in the patient’s family. The patient’s grandfather had dementia.
Psychosocial History: The patient was born in Columbia, Missouri, USA. Her mother raised her; her father died of cardiac arrest when the patient was four years old. Now she lives alone, is not married, has no children, and has a degree in screenwriting.
Medical History: In 2015, the patient started experiencing severe apathy and panic attacks. She did not go to the hospital then, attributing the symptoms to temporary fatigue due to workload. Two years ago, she turned to the psychiatrist Dr. Spencer, but after a short course of therapy, the patient stopped attending the sessions. She suffered head injuries several times due to falls, once in 2014 with a concussion.
Current Medications: The patient is now back on Mirtazapine 35mg once daily in the evening. In addition, she drinks the sedative Melatonin 3 mg an hour before bedtime. For the last four months, she has taken the homeopathic remedy Ignacia 10 drops twice daily.
Allergies: Experiencing an allergic reaction from anaphylaxis to bee stings. An anaphylactic reaction occurs within minutes of exposure to an allergen, and at least two body systems are involved.
Reproductive Hx: The menstrual cycle is regular, but once every three months, there are failures in the form of long delays from one week to complete absence. The patient was not pregnant or breastfeeding, but the patient used Quinol contraceptives twice. The patient practiced vaginal and anal intercourse while not experiencing sexual problems.
Review of Systems
GENERAL: There is fatigue and weakness, often for no reason. Weight loss is also observed.
HEENT: Eyes: There is no loss of vision, at times, there is a fuzzy image.
Ears, Nose, Throat: there is a frequent feeling of stuffiness in the ears and nose. Hearing is normal, but breathing is difficult due to allergic reactions.
SKIN: No rashes, eczema, or itching.
CARDIOVASCULAR: The patient has arrhythmia, especially at the slightest exertion. Chest pain occurs at intervals of about once a month.
RESPIRATORY: There is shortness of breath with moderate physical exertion. There is no cough and macroscopic discharge.
GASTROINTESTINAL: There is no nausea, vomiting, diarrhea, there are abdominal pains.
GENITOURINARY: No burning or hesitation when urinating, smell and color are standard.
NEUROLOGICAL: Headaches, dizziness, and fainting are present.
MUSCULOSKELETAL: The muscles are poorly developed, and there is no back pain.
HEMATOLOGIC: No bruising or anemia.
LYMPHATICS: Lymph nodes are slightly enlarged.
ENDOCRINOLOGIC: Patient-reports excessive sweating and heat intolerance.
GENERAL: The patient appears anxious. She is well-dressed and neat, but she presents signs of fatigue and weight loss.
SKIN: No lesions, rashes, injuries. The skin is soft and wet to the touch, the patient shows signs of sweating.
CARDIOVASCULAR: RRR, no gallops, no murmurs.
RESPIRATORY: Clear vesicular breathing bilaterally.
Diagnostic results: Depression Test Questionnaire, blood tests to exclude bacterial, viral, or parasitic infections, thyroid, urine toxicology.
Mental Status Examination: The patient is a 28-year-old Asian woman who presents distressed. She communicates well with the examiner, but her answers are short and not explanatory. She speaks clearly, no deviations are found in her movements, and her thoughts are not confused. She does not deny that she has suicidal thoughts, and she talks about her lack of sleep and food intake. Memory is not damaged, and concentration is scattered – the patient has difficulty explaining her mental state and describing the previous visits to the doctor.
Differential Diagnosis: The first differential diagnosis for the patient is hyperthyroidism, otherwise known as an overactive thyroid. The patient shows signs of weight loss, anxiety, difficulty sleeping, and tiredness which can be attributed to hyperthyroidism (Duval, 2018). Diagnostic tests are necessary to confirm or exclude this diagnosis completely, but the patient does not show signs of hyperactivity, and she experiences hypersomnia as well as insomnia. Nevertheless, heat intolerance is a significant symptom of hyperthyroidism, which strengthens the possibility of this diagnosis.
The second differential diagnosis is bipolar disorder. According to Takeshima et al. (2020), “bipolar disorder is characterized by alternating episodes of depression and mania or hypomania” (p. 247). The patient shows signs of depressive episodes, but there are no clear descriptions of manic episodes defined by elevated moods, hyperactivity, and delusions or hallucinations. Thus, this diagnosis is not supported by the available evidence.
Finally, another differential diagnosis is major depressive disorder (MDD). Depression is characterized by “long-term and persistent episodes of low mood, hopelessness, fatigue” (Litner, 2020). The symptoms are present in the patient, as she shows signs of low moods and suicidal ideations that are reoccurring and persistent. She also expresses a loss of enjoyment in her hobbies and at work, which further supports this diagnosis. However, additional diagnostic tests are necessary to exclude the endocrinological nature of her depressive moods.
The diagnosis of MDD seems appropriate for the patient, and her assessment appears comprehensive. This case has shown that therapy and initial diagnostic evaluations are not always successful in providing the patient with the best course of treatment. I would request more tests to eliminate physical illnesses and inquire more information about her current medications. The woman’s health is greatly affected by the health professionals, and the lack of proper diagnosis in her earlier encounters shows an ethical problem that the current specialist has to approach carefully. It is vital to consider the patient’s anxiety and mistrust of medical professionals to overcome the barriers to her treatment. The patient’s age allows her to build a social network of supportive individuals, but she currently does not have strong connections. This makes her vulnerable to the additional stress of loneliness and lack of attention to her problems.
Duval, F. (2018). Thyroid hormone treatment of mood disorders. Current Treatment Options in Psychiatry, 5(4), 363-376.
Litner. J. (2020). Affective disorders. Healthline. Web.
Takeshima, M., Utsumi, T., Aoki, Y., Wang, Z., Suzuki, M., Okajima, I., Watanabe N., Watanabe, K. & Takaesu, Y. (2020). Efficacy and safety of bright light therapy for manic and depressive symptoms in patients with bipolar disorder: A systematic review and meta‐analysis. Psychiatry and Clinical Neurosciences, 74(4), 247-256.