POSTPARTUM DEPRESSION

A 25-year-old female patient came to the ER with possible stroke symptoms. She had postpartum depression and anorexia. Her vital signs were stable, but she had weakness on her left side. She takes Lexapro for depression but stopped for a few weeks. She sleeps a lot, cries often, and has headaches. She has poor appetite and takes supplements to gain weight. Her labs showed high platelets and elevated BUN. Chest X-ray and EKG were normal. She has weakness on her left side and is nearsighted. Her weight is only 96 pounds. She has good support from her mother. Her main stressor is her ability to care for her baby. Hi, my name is Demi Ditt and I'm going to give you an assessment on my patient HH while I was in the ER to do my mental health clinicals. So my patient is a 25-year-old female. She actually came into the ER and she walked in. She presented with possibly stroke workup due to abnormal gait and she was also seen almost a week ago for postpartum depression and anorexia. So the reason that I did do my assessment on her was because of the postpartum depression because she continued to have these symptoms and also with the anorexia. So her blood pressure, her vital signs were good. Her blood pressure was 110 over 81 with respirations of 15. Her pulse was 70. Her SpO2 was 96%. Her weight is only 96 pounds and she is about 5'4". She came in, she said she went, earlier in the day she had a eye examination and upon the eye examination, the doctor said that it looked like she had possibly had a stroke. So he wanted her to come into the ER to get a full workup. She also told us while she was here, while we were doing her assessment, that she did have some weakness on her left side. So we asked her to stand up and attempt to walk and you could see where she was also dragging that left lower extremity. And upon my assessment that I did on her, she did say she had some weakness in her left hand too. But she hadn't fallen, she hadn't dropped her baby or anything like that. She doesn't drop anything. She said she just has a hard time so she has to ask her husband to help her out a lot. So I'll start with my assessment of needs. She did not complain of any pain. She denied all pain. She's, I told you her vital signs, her blood pressure and everything. The only medication that she was on was her Lexapro and I will explain that more. She's on Lexapro, it's an antidepressant. She is taking it related to her postpartum depression. It takes one to four weeks for it to, for you to feel its full effects. The only problem with that is that she was taking it when she first complained to her OB that she was feeling depressed and then she stopped taking it for a couple of weeks because they went out of town and she forgot her medications at home. And so she just now restarted taking her medication. That is the only medication that she takes. She said she, she told me that she sleeps anywhere from eight to 12 hours a day. She said that she didn't have any difficulties with falling asleep. She just sleeps for very long periods. When I asked her about her anxiety, she said that she didn't feel like she had anxiety, but she does cry a lot and that's why she feels like she's very depressed. She said she can cry with anything going on. All of a sudden she'll just start crying and she said she doesn't know why. She denies having any suicidal thoughts or any thoughts of doing any harm to her baby. She did not have any fever. Her skin color, it is pale. The tissue turgor was within normal limits. She didn't complain about being thirsty. She did tell me that her diet wasn't the best, that she does not eat very much. She may only eat one meal a day and she's been trying to take little supplements in between to hopefully help her to put on some more weight. Her urinary output, she said was good. She doesn't have any problems with urinating. She's not on any medications for like antibiotics or anything. And then as far as her lab test, her labs did come back. They did do a WBC. Her WBCs were within normal limits. It was 8.4. The only thing that was really abnormal was her platelets. They were a little high and also her BUN was a little elevated as well. They also did, I'm sorry, they also did a PT INR and that was within normal limits as well. Her cultures, they didn't do any cultures on her at all. She doesn't use any support devices. Like I said, she said she did not fall or have any near falls either. At home, she just, she really doesn't move around a whole lot as well. Her respiratory assessment, she says that she's never smoked. Although I could kind of smell like a smoky smell on her. So it may be her spouse may be the one that smoked. Her lung assessment, it was within normal limits. She did not have any abnormalities when I listened to her chest. No complaints of shortness of breath. She was not restless. She was not irritable. She did not have any complaints of fatigue. Although when I, I'm sorry, she did have complaints of fatigue. She says she does tire very easily. But she's not short of breath. She just gets tired quick. There's no confusion. No drowsiness. No anxiety really. And she says that she does have headaches every now and then. So she takes Tylenol for her headaches. Her respiratory rate was 12. Her rhythm was regular. And her depth, it was within normal limits as well. Her breathing was unlabored. And she does not use her accessory muscles when breathing. Her activity tolerance, she did have some weakness on that left side when she walked. And that's why she's actually here. She had a chest X-ray. And a chest X-ray was clear. There was no abnormalities on her chest X-ray. No cough. So therefore, there's no sputum that she coughs up. She doesn't have to splint. Like I said, her breath sounds were normal. No abnormalities upon auscultation. She did take a Lexapro, which is her antidepressant. Her labs, I went over her labs. She did have her chest X-ray as well. And it was clear. Her SDO2 was at 96%. And also, no ADGs were drawn. No other diagnostics were drawn. She does not use any type of support device. Her IV was health-locked. Her cardiovascular assessment, there were no abnormalities. No chest pains. No dyspnea. No edema in her feet. I did not notice any edema. She did not have any complaints of lightheadedness. Vascular symptoms, there were none. Activity with tolerance, there was no shortness of breath. She just feels fatigued because she's not very active. Her skin temp was warm and dry. Her capillary refill was within three seconds. And I've already given you her bottle signs. There was no edema to the upper or lower extremities. Her hair growth was normal. Her skin texture was normal. Her toes were normal. Her pedial pulses, their psalis, as well as posterior tibial were all present. And they were equal, bilaterally, and strong. As far as like her dress, the way that she dressed or carried herself, her hair did seem like it was very oily. She said that she bathed every day. We did discuss that. But, like I said, her hair looked real oily. Her clothes, they weren't dirty or anything. It just looked like something probably she wore around the house. I gave you her diagnostic test. And there was no EKG. Well, there was an EKG. There was no abnormalities with her EKG, no echo. There was no stress test either. As far as her neurological assessment, like I said, she did say she had headaches every now and then, no falls, no fainting. She wears glasses. And her glasses she wears because she is nearsighted, and I will explain that later on the later pages. Her motor, I did say that she has left-sided weaknesses. Her Glasgow Coma Scale, she was awake. She was awake-oriented times three. She was able to follow all commands. She's able to move her upper extremities, but there is noted weakness on the left side, upper and lower. No seizure activities. And I did already go over the vital signs and her medications. No CAT scan, MRIs, or EEGs. And let's see, as far as her GI, she is anorexic. Her weight was only 96.2 pounds, and her height was 5'4 1⁄2". Her anorexia, I'm going to say, is related to the depression characterized by current restrictions of nutritional intake that is necessary to maintain a minimally normal body weight, having an intense fear of gaining weight or becoming fat. Her teeth appearance, they were in fair condition. No dentures. Her fingernails, they were short. They were in good condition. They weren't dirty or anything underneath them. It's just, like I said, she denied smoking, but at the same time, you could smell like cigarette smoke on her clothing. Mica's membranes were pink and moist. Her skin turgor was good. Her condition of her mouth and throat, no problems. Her ideal body weight should be between 115 and 145 pounds. Her diet, she does not eat very well. She says she eats one to two meals a day. She does try to snack or even take some of the supplements to help her gain some calories. Her IV was helplocked. No complaints of nausea or vomiting. No, she didn't have any other real tests that were ordered. Like I said, the only medication that she takes is Lexapro, which is the antidepressant, and she does need to take it appropriately, and we did go over that and how long. And she is aware of how long it takes before the medication will actually kick in and start working. She says that she now has good support. Her mother is her support. Her last bowel movement was two days ago. She does say she does get constipated at times. So we talked about being a little bit more active and trying to put a little bit more fiber in her diet from the foods that she eats. Her current status is that she is married, but as far as her psychosocial, she is depressed. She has postpartum depression. She said they did diagnose her with that after she had her baby. She said that she just cries all the time. Her depression is related to feelings of worthlessness and states she's always crying. She doesn't know why. She tries to be happy, but she's just not. She does have a good relationship with her mother, and she said that is her number one supporter. Her mother is always trying to help her and make her feel better. She's always there to help her. She even told me that her mother was on the way to bring her some food while her and her husband were at the ER. Her dress was appropriate for the weather and the current conditions. Mainly her current stressor is just feeling that she's not going to be able to take care of her baby the way that a mother should. So she is aware that she does have a condition of depression. Her culture is American. She does not have any kind of spirituality, like religious preference. She says that she does not go to church. As far as her Erickson stage of development, I would say that it's intimacy versus isolation. At the ages of 18 to 40, this is a major conflict. Centers for forming intimate, loving relationships with other people, and I think that she feels like she's not going to meet up to the standards she should to be a mother, and therefore she's suffering from postpartum depression. As far as, I'm just looking through my notes, her baby, I'm sorry, her baby is seven months old. So she said that she's never done anything as far as to hurt her baby. She's just concerned about herself. Her mental status, she is cooperative. She is friendly. Her personal hygiene, I just think that she kind of had an odor to her. I just think that she probably doesn't take a bath every day, but it wasn't totally inappropriate. Her age versus actual age was appropriate. She does act her age. Her gait was unsteady. Like I said, her left side was some weakness. Her speech was kind of slurred, and it was kind of like she had a trembling speech whenever she talked. She was very attentive. She was relaxed. She was not agitated. She didn't seem suspicious or withdrawn. She used appropriate words. She even tried to smile at times. Her speech was not pressured or anything like that. She does not have any other type of medical history as far as, like, any type of schizophrenia or bipolar. She does not have any of that. This is really the only thing that she has going on with her right now. She is oriented times four. She feels like she is forgetful at times. Her attention span, she feels like, is decreased. And her thought process is logical, goal-oriented, no suicidal ideations, no rambling, no loose associations, none of that. She does not have any type of hallucinations or distortions or paranoia. Her husband was sitting right there while we did just about all of her assessments. She does feel like her judgment is rational, and she doubts herself at times because she feels like she may not make the best decisions for her and her baby. So that is her biggest concern. That is her main stressor. And she also, her mother, she said that her mother is her main support, and she did tell me she now has an appointment to what we call Spindletop, and it is for her depression. So she will be able to go and talk to someone about her postpartum depression. So she'll be able to see, like, a therapist there. She felt like her sexual patterns were just within normal limits. She said that she does have interest in sexual activities with her husband. She's just not, she doesn't feel like she's very active. As far as her spiritual beliefs, she said that she did decline to even talk to a chaplain, and she said that she does not go to church or anything like that, so she doesn't have, like, a religion or anything that she claims. Other than that, that is it. That's the end of my assessment. Thank you.