Suzanne Year Homemaker Question & Answer Guide (With Explanation)
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Original Question
HPI Suzanne is a 42 year old homemaker and mother of 4 children (ages 9, 10, 13, 14). She presents to the PMHNP on referral from her PCP. Suzanne describes low energy, difficulty sleeping, with poor concentration. She reports she sometimes forgets to eat during the day because she is nervous about her husband. She has caught him having an affair. She admits to having crying spells and anhedonia. You discover she has a passive death wish, but denies SI or plan. HISTORY Past psychiatric history of depression on and off since age 15 without history of treatment, along with what is described as post partum depression with all 4 children. Past medical history of hypothyroid, HTN, asthma and seasonal allergies. Normal pregnancies, all vaginal births. Surgical history includes cholecystectomy at age 22. Family history of depression -mother and maternal aunt. She thinks her grandmother attempted suicide before she was born. Social history includes HS and college graduate. BSN, worked 6 years as a nurse before her first child. She married her husband at age 24. Married x 18 years. Her parents are living, but live out of state. She has one older brother who lives close to her, but is always out of town for his job. She feels she does not have much social or family support. Suzanne denies tobacco use and drinks wine ‘rarely’. Denies drug use. MSE General appearance: appropriate hygiene, mildly unkempt, obese, appears tired Behavior/attitude: avoidant eye contact, calm, cooperative Psychomotor activity: Psychomotor retardation Mood: ‘sad’ Affect: dysphoric, constricted, congruent, stable Speech: low volume, slowed rate, latency, sparse Thought Process: organized, linear, appropriate Thought Content: +Passive death wish. Denies SI or Plan. Denies HI. No delusions noted. Thought Perception: Does not endorse AH or VH. Does not appear to be responding to hallucinatory stimuli Cognition: A&O x3. Unable to do serial number testing, impaired short-term memory with difficulty with immediate recall. Proverb testing without difficulty. Insight: fair Judgement: satisfactory Discuss and answer the following: What is the most probable diagnosis? What further assessment is needed? What differential diagnoses would you consider? What medical problems would you like to rule out? What lab work would you order? What screening tool would you use?
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