Anxiety and depression are the most common psychiatric problems you will encounter in your primary care practice.

Review this case study

HPI: KB, 55 year old Caucasian female who presents to office with complaints of fatigue. The fatigue has been present for 6 months and seems worse in the morning, improving slightly through the day. KB reports a lack of energy and "loss of joy". States" I really don't feel like going anywhere or doing anything" Reports she often has difficulty staying on task and completing projects for work. She reports not feeling hungry and does not feel rested when she wakes up in the morning. KB is a widow for 2 years, social events that are couples only can make her symptoms worse. She tries to do at least one social activity a week but it can be really exhausting. Her husband died in their car while she was driving him to the hospital and sometimes driving in that car makes all the memories come back. She recently got a puppy, which she thought would help with the loneliness but the care of the puppy seems overwhelming at times. Rest and exercise, specifically yoga and meditation seem to make her feel better. At this time she does not want to do either. She has not tried any medications, prescribed or otherwise. She reports drinking a lot of coffee, but that does not seem to help.

Current medications: Excedrin PM about once a week when she can't sleep, seems to help a bit. NKDA.

PMH: no major illnesses. Immunizations up to date.

SH: widowed, employed full time as a manager. Drinks wine, 1 glass every night. No tobacco, no illicit drugs. Previously married while living in France, reports an abusive relationship. The French government gave custody of her son to the ex-husband. She returned to US without her son 10 years ago. She sees her son two times a year, they skype and text "all the time" but she misses him.

FH: Parents are alive and well. Has one son, age 21, he is healthy but lives in France with his father.

ROS

CONSTITUTIONAL: reports weight loss of 2-3 pounds, no fever, chills, or weakness reported

HEENT: Eyes: No visual loss, blurred vision, double vision or yellow sclera. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose or sore throat.

CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations or edema.

RESPIRATORY: No shortness of breath, cough or sputum.

GASTROINTESTINAL: Reports decreased appetite for about 3 months. No nausea, vomiting or diarrhea. No abdominal pain or blood.

NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.

GENITOURINARY: no burning on urination. Last menstrual period 4 years ago.

PSYCHIATRIC: No history of diagnosed depression or anxiety. Reports great anxiety due to verbal and concern for physical abuse, reports feeling very sad and anxious when divorcing and leaving her son in France. Did not seek treatment. She started to feel better after about 4 months.

ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. No polyuria or polydipsia

ALLERGIES: No history of asthma, hives, eczema or rhinitis.

Discussion Questions:

1. Research screening tools for depression and anxiety.

• Choose one screening tool for depression and one screening tool for anxiety that you feel are appropriate to screen KB.
• Explain why you chose that particular tool for KB. Score KB based on the information provided (not all data may be provided).
  
•  Include what questions could be scored, and your chosen score. Assume that any question topics not mentioned are not a concern at this time. 

4. Identify your next step for evaluation and treatment for KB. Include any necessary physical medicine evaluation.
5. What medication, if any, would you recommend for treatment? Provide the rationale. This should include the medication class, mechanism of action of the medication and why this medication is appropriate for KB. Include initial prescribing information and education to include side effects and when KB should notice efficacy.
6. If the medication works as expected, when should KB expect to start feeling better?