Practice this case based on how you are assessed in your OSCEs, and use the relevant sections for general revision. 🤓
Doctor Instruction:
You are a doctor working in family medicine. A 28-year-old female, Emily Lord, came in today due to low mood. Please take a mental health history and perform an appropriate examination.
Patient History:
Emily Lord, a 28-year-old female, works in IT.
Over the past two months, you have been feeling low most days. You feel like you often lack the energy to do the general things in life e.g. getting out of bed, cooking, doing the laundry…etc. You lack the motivation to do anything. You also can’t concentrate on reading the newspaper or watching the television.
You no longer enjoy playing sports e.g. badminton which you used to, and you have been missing a lot of games with your friends lately – which you feel bad about.
You have very poor sleep and often find yourself waking really early in the morning e.g. 5 am for no reason. Because of this, your colleagues at work are starting to notice that you have been working a lot slower than usual – you think this is due to a lack of sleep.
You have a low appetite. Don’t eat very much. Because of this, you think have lost a bit of weight.
You currently have no suicidal/ self-harm thoughts. No previous episodes of mania, however, you do feel anxious all the time with worrying thoughts. Sometimes, you just can’t relax your body muscles.
Ideas, Concerns, Expectations:
You broke up with your long-term boyfriend before this started since he cheated on you. You think your mood is related to this and you can't believe this happened you. You now feel worthless and do not know what to do as you had many plans previously with your ex-partner. You are worried as this is now starting to affect your performance at work. You would like to seek help to improve your mood and sleep.
Past Medical History:
No medical/surgical history
No previous psychiatric history/admission.
No previous suicidal /self-harm attempts or thoughts.
Drug History:
Currently on the combined oral contraceptive pill.
NKDA
Family History:
Brother suffers from anxiety and depression.
Auntie was diagnosed with Bipolar disorder when younger.
Social History:
Working as an IT analyst.
Drink a glass of wine every night.
Never smoked.
No recreational drug uses.
Currently living alone since ex-boyfriend moved out 2 months ago.
Support network: Mum lives close by, you have friends close by but don’t want to rely on them.
Examination Findings:
Mental state examination:
Appearance: normal weight, dressed in pyjamas with reduced personal hygiene. Clothing is not appropriate for the weather or time of day.
Behaviour: Patient appears engaged with reduced eye contact. Body language appears slow and down, but there are no abnormal movements or postures.
Speech: Slow rate of speech that is monotonous. Reduced quantity of speech with normal volume. No slurring or stuttering.
Mood and affect: patient says subjectively she feels low, objectively she has sad affect that is fixed. Their affect is congruent with their thoughts.
Thought: No suicidal/self-harm/ harming others thoughts. No delusions.
Perception: No hallucinations.
Cognition: Orientated to time, place, and person. Normal cognition.
Insight: Good insight into their current low mood. Seeing this as a problem and would like to seek help.
Differentials:
Depression - due to core symptoms: anhedonia, low mood, lack of energy, but also lack of concentration, loss of libido, early morning wakening, psychomotor retardation…etc. (>2 weeks duration), Family History, Stressful life event – being cheated on, Predisposing factors: female sex.
Adjustment disorder - Due to identifiable precipitating event (ex-boyfriend cheating).
Generalised anxiety disorder - Lack of energy, muscle tension, and anxiety which can be mixed with depression. There is also a family history of anxiety. This has however NOT lasted for more than 6 months.
Bipolar disorder - due to depressive episode and most people with bipolar disorder have a depressive episode. It may be that this patient has not crossed over into a manic episode yet. However unlikely to diagnose as we have not seen a manic episode.
Organic causes - can present with depression symptoms) - hypothyroidism, anaemia, diabetes, hypercalcemia.
Investigations:
Bedside:
Diagnostic questionnaires e.g. PHQ-9, HADS, and Beck’s depression inventory.
Blood Test:
FBC (anaemia), TFT (hypothyroidism, U&Es/LFTs/calcium levels (biochemical abnormalities), glucose (diabetes).
Imaging:
MRI or CT Scan if features suspicious of intracranial lesion e.g. unexplained headache/personality change.
Data Interpretation: