The Diagnostic Process: Differential and Priority

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The Diagnostic Process: Differential and Priority

Abstract

The current study covers a patient from a case study requiring identification of the patients condition based on presentations to the physician. Based on the case, the analysis identified the top four differential diagnoses, namely depression, generalized anxiety disorder, chronic fatigue syndrome, and insomnia. This is followed by the identification of depression as the priority diagnosis. The study identified diagnostic tests to guide decision-making and therapeutic interventions. The sections covered are in addition to referrals, collaboration and follow-up of the patient.

Top four differential diagnoses

Spencer presents with different signs and symptoms of depression, including the feeling of emptiness, sadness, irritability, guilt, hopelessness, and anxiety. The girl reports little interest in previously interesting activities, complains of tiredness, low concentration and poor memory of details. She complains of insomnia and lack of appetite. Even though she asserts she cannot commit suicide, she says that she has occasional suicidal thoughts. Furthermore, Spenser complains of headaches, fatigue, poor decision-making, helplessness and worthlessness.

Clinical description

According to Shaffer and Waslick (2008), depression can present as a component of many different clinical problems that are common reasons for referral to mental professional. The presentation includes distinct and enduring mood changes, school problems, family conflicts, suicidal crises, social issues, and somatic symptoms. Shaffer and Waslick (2008) highlight the significance of other childhood disorders presented by the patient in making the differential diagnosis.

Generalized anxiety disorder (GAD)

Spenser presents with different emotional, behavioral and physical symptoms, which are typical of generalized anxiety disorder. Emotionally, Spencer presents constant worries, uncontrollable anxiety, intrusive thoughts, uncertainty intolerance and an apprehensive feeling. Behaviourally, Spenser complains of lack of relaxation or enjoyment, difficulty in maintaining focus, feeling overwhelmed and trying to avoid anxious situations. Physically, the girl feels tense, has body aches, has trouble falling asleep, and waking in sleep, restlessness, edgy and nauseous.

Clinical description of generalized anxiety disorder

As asserted by Blazer and Steffens (2009), the clinical features of a generalized anxiety disorder include situational fear, automatic arousal, obsessions and compulsions, situational avoidance, anticipatory worry, and panic attacks. The disorder is marked by behavioral avoidance and fear or worry with irritability and sleep disturbance being common occurrences. Generalized anxiety disorder is characterized by excessive anxiety and worry about a number of events or activities with individuals finding this worry difficult to control and associated with several physical symptoms such as muscle tension, fatigue and restlessness (Weiner & Freedheim, 2003).

Chronic Fatigue Syndrome

From the case, Spencer presents with long feelings of tiredness, forgetfulness, aches, headache, and difficulty in maintaining focus. She complains of psychological problems such as irritability, panic attacks, mood swings and anxiety. The girl also presents with restless sleep, she grows increasingly restless, sinus surgery and a history of mononucleosis in her family.

Clinical description of Chronic Fatigue Syndrome

According to Katz and Jason (2013), clinical description of Chronic Fatigue Syndrome includes controversial and complex conditions that include severe fatigue as well as cognitive and musculoskeletal signs and symptoms. Patients with chronic fatigue syndrome complain of functional problems and disruption of learning, especially in teenagers. Katz and Jason (2013) go on to assert that a history of infectious mononucleosis predisposes individuals to suffer from chronic fatigue syndrome. In his study, Venes (2013) identified specific signs and symptoms of the syndrome, which include low-grade fever, muscle weakness, headaches, confusion, thinking difficulty and sleep disturbances, among others. Furthermore, the syndrome may result from neurological disruptions, compromised immune system, endocrine and viral infection (Venes, 2013).

Insomnia

Spenser may be suffering from insomnia because of the signs and symptoms she presents to the doctor. The girl complains of lying in bed for a long time up to late before falling asleep, remaining awake for most of the night, sleeping intermittently for short periods, and waking up early in the morning. The lady feels depressed, uses no seat belt, feels sad in bed, tired during the day, has no sex drive, has an insomnia history in the family, has low levels of energy, does not sleep during the day, and has difficulty in falling asleep.

Clinical description of Insomnia

According to McArthur and Borsini (2008) insomnia is a heterogeneous disorder of reduced sleep quality, duration, or efficiency. They went on to assert that individuals suffering from insomnia often have high rates of absenteeism from daily activities, visit healthcare more often, and they stand high chances of developing depression (McArthur and Borsini, 2008). Mindell and Owens (2003) supported this position, defining insomnia broadly as subjective difficulty in initiating and/or maintaining sleep, early morning awakening and non-restorative sleep. In most cases, insomnia causes the person suffering to experience daytime problems such as fatigue, low energy, cognitive impairment and irritability. Insomnia involves difficulty falling asleep and/or maintaining sleep, including early morning awakenings and in many cases, the symptoms are secondary to another sleep or medical disorder (Mindell & Owens, 2003).

Priority diagnosis

Based on the cues, patterns, subjective and objective information, the analysis chose depression as a priority diagnosis. Furthermore, examination of the rationale and clinical description of the top four differential diagnoses, all of them point to depression as a priority diagnosis.

Cues and patterns

The cues and patterns revealed through Spencers case indicate that she is suffering from depression. Real happenings in her life, for instance being a teenage female, among other things, predispose her to high levels of stress. For instance, Spenser indicates she is in college and experiences financial constraints in addition to being unemployed, which increases levels of stress leading to depression. In her social life, Spenser says she has no friends except her boyfriend and a few close friends and her family. In college, she is not comfortable with her roommate who she fears confronting. Other patterns and cues indicating depression include difficulty in sleeping, feeling of unworthiness, insecurity, tension headaches, mood swings, low energy and tiredness.

Objective/subjective information

Objectively, the physicians observations show a person with relatively slow speech, tired appearance, not belting her seat, low mood and flat affect, which may be an indication of someone under depression. The subjective information about Spencer makes it more convincing. Spenser is a teenage college student and reports mood swings and low levels of energy. The girl complains of lacking an appetite for long periods and fears his lack of sex drive and lack of organism in recent times. The teenager also uses acetaminophen to relieve tension headaches that occur up to twice a week. Spencer had a slow recovery to sinus surgery, which was followed by depression and insomnia in her time in high school. The conditions improved after previous visits to the psychiatrist, which indicates she must have been depressed. Furthermore, Spencer admits to developing suicidal thoughts with no real intention of suicide because of an experience of suicide with her teacher. Other cues include a feeling of self unworthiness, has not made many friends other than her boyfriend and she feels insecure.

Pathophysiology of depression

The pathophysiology of depression is based on neurotransmitters, mood and other depression theories. Serotonin and noradrenaline are vital in the development of depression because of their physiological ability to regulate emotional behavior including mood. The neurotransmitters such as serotonin control a persons pain, levels of anxiety, arousal, pleasure, sleep behavior and panic. According to the biogenic amine theory, depression is an outcome of deficiencies in the monoamines serotonin and noradrenaline. The general agreement about depression pathophysiology indicates a wide array of factors that contribute to the condition. For instance, in the case of Spencer, the girl faces a number of factors that affect the neurotransmitters, their release and binding, which results in an escalation of the condition. Noteworthy, the college student has problems of loneliness, relocation issues with her sister and friend, educational demands, missing family members, and financial difficulties because of lacking employment, which may cause transmitter imbalance in the body.

Additional interventions

Additionally, the doctor can intervene by ensuring social support for Spencer and appointing close members of the family to provide updates on any developments. Furthermore, considering the medical history of the girl, it is important to terminate medications such as oral contraceptives that may contribute to the escalation of depression.

Diagnostic tests

The physician conducts three major diagnostic tests and examinations to guide clinical decision-making by eliminating other issues resulting in the symptoms, checking related conditions and pinpointing a diagnosis. First is the physical exam and asking of questions about Spencers health because of the possibility of an underlying health problem. Second, lab tests such as a complete blood count or thyroid testing help ensure proper physiology. Finally, psychological evaluation helps in identifying depression signs and the physician achieves this by asking Spencer about her symptoms, behavior patterns, feelings and thoughts (Hand, 2014). This includes a feeling of a questionnaire to answer other questions.

Therapeutic interventions

Considering the case of Spencer, the physician can use pharmacological and non-pharmacological options. However, pharmacological intervention is applicable in case the patient fails to respond to non-pharmacological interventions. The first intervention is recommending physical exercise for Spencer and considering she has a job to train aerobics, it would help her in alleviating the symptoms of depression (Taliaferro, Rienzo, Pigg, Miller & Dodd, 2009). Second, the physician can intervene through measures that enhance health nutrition and wellness. Promoting wellness and nutrition helps patients in alleviating signs and symptoms of depression (Taliaferro et al., 2009). Cognitive behavior therapy is important in making Spencer be aware of herself and her problems to embrace mechanisms of dealing with the issues facing her effectively (Stein, Zitner & Jensen, 2006). In case the methods do not work, the physician may consider prescribing antidepressants such as Escitalopram, Citalopram, Fluoxetine and Sertraline.

Referral and collaboration

In case the physician is not in a position to address all patient needs and the patient fails to respond to treatment methods, he can collaborate with other care providers for depressed patients through referrals and consultations (Buttaro, Trybulski, Bailey & Sandberg-Cook, 2012). Health social support team is important in making professional inquiries on depression management to provide feedback on effective treatment of the condition. Further de-escalation of the condition would need referrals to psychiatrists and other professional experts.

Journal article on depression Collaborative care to improve the management of depressive disorders: a community guide systematic review and meta-analysis. American journal of preventive medicine, 42(5), 525-538.

The article discusses the general concept of depression with a particular focus on using collaboration among health care professionals to improve the management of depression. In achieving this, the researchers analyzed data from care providers to understand the level of collaboration in diagnosing and managing the disorder. From the analysis, the study revealed the effectiveness of collaboration in achieving clinically meaningful improvements in depression outcomes and public health benefits in a wide range of populations, settings, and organizations (Thota et al, 2012). Through collaboration, health care professionals support each other in providing effective interventions for patients in primary care.

Follow up

Follow-up of Spensers case will be on a weekly basis in the initial stages where the physician asks for a personal meeting or makes phone calls. In the follow-up, the doctor engages in treatment, ensures treatment is as planned, manages side effects, and in case of referrals, the follow-up checks on compliance. After the first one month, the following happens on a monthly basis and reduces, as the patient gets well. The follow-up would be essential because healthcare providers will frequently monitor the progress of the patient. In case of any unwanted symptoms, appropriate care and/or medications would be offered.

References

Blazer, D. G., & Steffens, D. C. (2009). The American Psychiatric Publishing textbook of geriatric psychiatry (3rd ed.). Washington, DC: American Psychiatric Pub.

Hand, C. (2014). Living with depression. Edina, MN: ABDO Publishing Company.

Katz, B., & Jason, L. (2013). Chronic fatigue syndrome following infections in adolescents.Current Opinion in Pediatrics, 25(1), 95-102.

McArthur, R. A., & Borsini, F. (2008). Animal and translational models for CNS drug discovery. Amsterdam, Netherlands: Elsevier/Academic Press.

Mindell, J. A., & Owens, J. A. (2003). A clinical guide to pediatric sleep: diagnosis and management of sleep problems. Philadelphia, PA: Lippincott Williams & Wilkins.

Shaffer, D., & Waslick, B. D. (2006). The many faces of depression in children and adolescents. Washington, DC: American Psychiatric Pub.

Stein, R., Zitner, L., & Jensen, P. (2006). Interventions for adolescent depression in primary care. Pediatrics, 118(2), 669-682.

Taliaferro, L. A., Rienzo, B. A., Pigg, R. M., Miller, M. D., & Dodd, V. J. (2009). Associations between physical activity and reduced rates of hopelessness, depression, and suicidal behavior among college students. Journal of American College Health, 57(4), 427-436.

Venes, D. (Ed.). (2013). Tabers Cyclopedic Medical Dictionary (22nd ed.). Philadelphia, PA: F.A. Davis.

Weiner, I. B., & Freedheim, D. K. (2003). Handbook of psychology. Hoboken, NJ: Wiley.

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