Introduction depression

“Doc, I’m Tired and Have Little Energy”

Mr. George is a 44 year old male with a past medical history of hypertension for 4 years. He comes to this visit requesting his serology results from his last visit. At that time, he complained of feeling tired and having little energy especially in the morning hours. Mr. George denied shortness of breath, chest pains, palpitations, fevers, or anxiety. No GI complaints, no melena, no hematochezia. He read on the internet about thyroid disease, anemia, and Lyme disease which all could explain his symptoms. He has not been traveling outside of Manhattan and did not visit a wooded area recently. Those laboratory tests from his last visit one month ago are completely negative today. He also had a recent annual physical examination two months ago and everything was normal.

Patient Chart | Mr. George
Past Medical History – Hypertension

Medication – Hydrochlorothiazide 25mg once a day

Past Social History – Works as an office manager. Heavy stressors under a new boss. Married to his wife of 14 years, monogamous, and has one 10 year old daughter. Denies alcohol, drug, and tobacco use. Sexually active with his wife about once a year only – “as we just don’t have time or energy anymore.” No interpersonal conflicts at home with family, although she laments that they don’t go out much anymore.

Family History – Father is alive and suffers from gout, hypertension, and cholesterol. Mother is alive and has been diagnosed with diabetes last year.

ROS – He has trouble falling asleep almost every night and he wanted to ask you about “safe” sleeping pills that he heard about on television commercials. This has been going on for 8 weeks.

BP 135/80 P70 R21 Wgt 210 lbs (was 195 lbs 5 months ago)
General – In no acute distress
HEENT – WNL, No JVD, No thyromegaly or nodules
Lungs – CTA B
Cor – RRR No M
Abd – S / NT Pos BS
Ext – No C / C / E

Neuro – No tremors; reflexes 2+ upper and lower extremities; normal hand to nose coordination, normal gait – essentially a normal neurological exam.

Psych – Admits to less pleasure in doing things he used to like to do, and feels down occasionally but does not feel he is depressed. He has increased appetite having gained 15 pounds since his visit 5 months ago. He attributed the weight gain to stress at work. Denies suicidal ideation or homicidal ideation. He also notices trouble concentrating at work and “can’t get into television shows or movies” in the same way he did prior.

Guaiacs Neg x 3
TSH 1.44 (WNL 0.34 – 4.25)
Chem 7 WNL
Hct 40
Lyme Titers Neg

Question 1:

Mr. George feels tired and has little energy. His physical examination and lab work are negative. He completely denies being depressed. Upon further questioning he does describe losing interest in activities he used to like to do, increased appetite and weight gain, problems with concentration, and insomnia. At this point, Mr. George wants to know the next appropriate step in his assessment and management. Of the following, which one is the most appropriate recommendation? (Choose the best answer.)

  1. Perform a whole body CT or MRI scan to look for an occult source
  2. Recommend that Mr. George and his family go on a vacation
  3. Consider testing for underlying neurological disease
  4. Refer him to a gastroenterologist for a colonoscopy screen
  5. Have Mr. George complete a standardized screening questionnaire for depression
  6. Write him a prescription for sleeping medications

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