Question

CASE STUDY

Jane is a 32 year old married woman. She requested an urgent appointment to see you in your primary care setting after a recent car accident. She hit the car in front of her at a busy intersection resulting in damage to both cars, she reports even "though I felt weak I did the right thing", asking the other involved driver if he was ok and filing the necessary insurance paperwork. In the electronic health record (EHR) you note a memo to the chart detailing a phone call from Jane's husband John about his concerns. He's worried that she's been acting odd, even before the accident, she's been drinking more and was racing home from the mall to be home when he got home and he thinks it is so he wouldn't know about where she had been. He says he has the credit card bills to prove she is doing a lot of shopping. At the end he mentioned in passing that she failed the field sobriety test.  

As you further review the EHR you see the note from the last visit in which Jane complained of being worn out, dejected, even a little hopeless. They have a 1 year old son who seems to be having some issues. She had a difficult pregnancy, you are just about the review the Edinburgh test when your assistant comes to get you for the exam.  

As you ask her about her chief complaint she is irritable "isn't it obvious, I got hurt in the accident." As she talks she says "I've been on an emotional roller coaster ever since".  I have a headache, now I'm feeling dizzy.

Base on the above case study, please answer the following questions.

1.    What are the top two key physical assessment questions to ask? Why are you prioritizing these questions?

2.    Do you read the memo to the chart and if you do, do you address the concerns mentioned there and if you don't, why not?

3.    An Edinburgh test is mentioned in the case study, what other psychological assessment tool would you have the patient do and why?

4.    What are your top two-four medical and psychiatric differential diagnoses given the information in the case?

5.    What is your final psychological diagnosis? Include the ICD 10 code

6.    Support your answer in question 5 with the criteria you believe Jane meets.

7.    List, in order of priority, the lab tests/imaging/specialty referrals you think are appropriate for Jane if any and your reasoning.

8.    What treatments will you order for the patient and why?

Answer 1

Top two key physical assessment questions to be ask? Why are you prioritizing these questions?

1. Any signs and symptoms of internal or external head injury because of the accident : Prioritize this question because while asking about her chief complaint she is irritable and says I have a headache, now I'm feeling dizzy and all . Also her husband says about her behavior of acting odd, alcoholism , depression etc

2. Mental status examination to assess the post partum depression by Edinburgh test : Prioritize this question because many of the questions in this Edinburgh Postnatal Depression Scale  (EPDS) is matching with Janes problems

EDINBURGH POSTNATAL DEPRESSION SCALE  (EPDS)

Please select the answer that comes closest to how you have felt in the past 7 days:

1. I have been able to laugh and see the funny side of things As much as I always could Not quite so much now Definitely not so much now Not at all

2. I have looked forward with enjoyment to things As much as I ever did Rather less than I used to Definitely less than I used to Hardly at all

3. I have blamed myself unnecessarily when things went wrong Yes, most of the time Yes, some of the time Not very often No, never

4. I have been anxious or worried for no good reason No, not at all Hardly ever Yes, sometimes Yes, very often

5. I have felt scared or panicky for no very good reason Yes, quite a lot Yes, sometimes No, not much No, not at all

6. Things have been getting on top of me Yes, most of the time I haven't been able to cope at all. Yes, sometimes I haven't been coping as well as usual No, most of the time I have coped quite well. No, I have been coping as well as ever.

7. I have been so unhappy that I have had difficulty sleeping Yes, most of the time Yes, sometimes Not very often No, not at all

8. I have felt sad or miserable Yes, most of the time Yes, quite often Not very often No, not at all

9. I have been so unhappy that I have been crying Yes, most of the time Yes, quite often Only occasionally No, never

10. The thought of harming myself has occurred to me Yes, quite often Sometimes Hardly ever Never

2. Do you read the memo to the chart and if you do, do you address the concerns mentioned there and if you don't, why not?

Yes I addressed the concerns mentioned there

3. An Edinburgh test is mentioned in the case study, what other psychological assessment tool would you have the patient do ?

Ø Beck Depression Inventory (BDI)

Ø Quick Inventory of Depressive Symptomatology-Self-Report (QIDS-SR)

Ø Patient Health Questionnaire (PHQ-9)

Ø Social Adjustment Scale-Self Report (SAS-SR)TM

4. What are your top two-four medical and psychiatric differential diagnoses given the information in the case?

Ø Post partum psychosis

Ø Depression

Ø Generalized anxiety disorder

Ø Substance abuse : alcoholism