HPI (OLDCARTS) Jacqueline Russell is a 17-year-old female who comes in the clinic with complaints of generalized fatigue which started two months ago. Accompanying symptoms include anxiety, anhedonia, irritability, and problems concentrating. Major life changes include recent breakup with her boyfriend and pressure in school while expected by her parents to have a scholarship. She stated that she gets enough sleep but still feel tired upon waking up. Key findings include being overweight, easily cries, unintentional 25-30 weight gain last year, history of marijuana use, Acanthosis Nigricans, and striae on abdomen and buttocks. She denies taking any medications other than Ibuprofen for menstrual cramps. She occasionally drinks beer. The patient skips breakfast but eats high calorie foods like pizza and French fries several times per week. The patient denies any suicidal ideations but stated that she wants to “disappear” and not deal with her situation. Risk factors include family history of diabetes II and obesity. Lab findings are negative for anemia, negative urine drug screen, normal T4, TSH levels, and CBC. Key Findings: BMI 28.8 (overweight) Patient is reluctant to make eye contact Crying Pressure from being a senior at school Mother made her come, pressure from parents Per patient gets enough sleep but wakes up tired Unintentional 25-30 weight gain last year Stretch marks Marijuana use Hx with old boyfriend Breakup with boyfriend Low self-esteem Skips breakfast, eats high calorie foods like pizza and french fries several times per week Constantly snack at night to keep going Anhedonia in school and leisure activities Upset, irritable, angry, frustrated, and cries daily Feels irritable and annoyed a lot by family and parents, they blame on her periods. Problems concentrating daily Wants to disappear and not deal with situation Occasionally drinks beer Acanthosis Nigricans at nape Striae on abdomen and buttocks Meds: Takes Ibuprofen for menstrual cramps, pain is not bad per patient. Social Tried marijuana last year with old boyfriend, denies any other recreational drugs Used to baby sit for a family neighbor Primary Dx: Major Depressive Disorder – Symptoms similar to Jacqueline are depressed mood, irritability, markedly diminished interest and pleasure in usual activities, and symptoms that lasts at least two weeks. Common symptoms of depression also include change of appetite (25-30 lbs. weight gain), low energy and fatigue, and difficulty concentrating. MDD is diagnosed if there have been at least two weeks of depression with at least four accompanying symptoms of depression. General Anxiety Disorder – The most common comorbidity with depression is anxiety disorder. Major symptoms similar to Jacqueline are unexplained fatigue, irritability, difficulty concentrating, DDx: Type II Diabetes Mellitus Hypothyroidism Fatigue O-2 months ago L-generalized D-Constant per mother CA-Pressure from school as a senior A-Gets enough sleep but still wakes up tired R-? TS-Don’t feel like doing anything 1. Therapeutic & Non-Therapeutic Modalities Consider cognitive behavioral therapy and psychoeducation in collaboration with a pediatric psychiatrist. Antidepressant medications may be considered first-line treatment for moderate-tosevere depression or depression that has not responded to an adequate trial of psychotherapy Family interventions and involvement in cognitive-behavior therapy Fluoxetine (Prozac) 10 mg PO daily. Fluoxetine has the strongest evidence for use in pediatric depression (Mullen, 2018). May take at night if feelings of drowsiness occur during the day.