Angela is a young female that presents to the provider with increased irritability and tearfulness.
She is at the office today at the urging of her parents. She verbalizes increased fatigue over the
past two months a
...
Angela is a young female that presents to the provider with increased irritability and tearfulness.
She is at the office today at the urging of her parents. She verbalizes increased fatigue over the
past two months and recent weight gain. She also presents with increased irritability and
tearfulness. Angela describes always being tired and an increase in anhedonia, or loss of interest
in every-day activities. She is obese with mild acne, states she’s feels unhappy with the way she
looks. Currently Angela denies any suicidal ideation.
Upon completion of assessment, it appears that Angela is suffering from adolescent
depression disorder. However, it is important to complete lab work to rule out any other cause of
her symptoms. A complete blood count, thyroid studies and heterophile antibody test has been
completed to determine if some pathological reason is contributing to Angela’s fatigue and lack
of energy. The CBC has come back within normal limits, ruling out acute infection as a cause of
Angela’s symptoms. The thyroid studies are also in normal limits, ruling out thyroid disorder as a
cause of symptoms. Due to Angela’s age and symptoms a heterophile antibody test is appropriate
to rule out mononucleosis as a cause of symptoms. This test came back negative, ruling out
mononucleosis. A urine cortisol test was completed to rule out pathological causes of Angela’s
symptoms. This test was within normal limits.
Due to Angela’s personality changes and irritability, a urine drug screen is appropriate.
This test was negative for all drugs. Angela admitted to being sexually active with her former
boyfriend, so a pregnancy test is appropriate. The pregnancy test was negative.
Angela is mildly obese and has a family history of diabetes mellitus. A fasting blood
sugar and hemoglobin A1C are appropriate to be checked. Angela’s blood sugar and hemoglobin
A1C are within normal limits.
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Running Head: AC PATIENT ENCOUNTER 3
After ruling out pathological reasons for Angela’s symptoms, the healthcare provider can
confidently begin treating for adolescent depression disorder. Angela will need a combination of
both pharmacotherapy and psychotherapy.
Angela should be started on a selective serotonin re-uptake inhibitor (SSRI) (NIMH,
2018). SSRI’s are the first line antidepressant (NIMH, 2018). SSRI’s are used because they have
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