From the Guidelines
The most appropriate next step in evaluating this 30-year-old woman with insomnia, fatigue, and unintentional weight loss is to screen for major depressive disorder using a validated tool like PHQ-9, as mental health conditions commonly present with these symptoms 1. Given the patient's symptoms of poor sleep, fatigue, and unintentional weight loss, which have been ongoing for 2 months and are affecting her ability to work, it is crucial to consider the potential for a mental health disorder, particularly major depressive disorder. The patient's normal TSH and negative hCG help to rule out thyroid dysfunction and pregnancy as causes of her symptoms.
Key Considerations
- The patient's symptoms of insomnia, fatigue, and weight loss are nonspecific and could represent various conditions, including malignancy, autoimmune disease, chronic infection, depression, or substance use disorder 1.
- The patient's history of seasonal asthma and use of albuterol as needed is noted, but there is no indication that her asthma is currently uncontrolled or contributing to her symptoms.
- The patient's physical examination is normal, which suggests that there may not be an underlying medical condition causing her symptoms.
Potential Next Steps
- After screening for major depressive disorder, additional testing might include cortisol levels to assess for adrenal dysfunction, HIV testing, and possibly autoimmune markers if suggested by other findings 1.
- A sleep study could be warranted if the history suggests a primary sleep disorder, but given the patient's symptoms of fatigue and weight loss, it is more likely that her insomnia is related to an underlying mental health condition rather than a primary sleep disorder.
- Complete blood count, comprehensive metabolic panel, and inflammatory markers (ESR, CRP) would help screen for anemia, infection, liver or kidney dysfunction, and systemic inflammation, but these tests should be guided by the patient's symptoms and physical examination findings.
Prioritizing the Patient's Quality of Life
- It is essential to prioritize the patient's quality of life and address her symptoms in a comprehensive and systematic manner, rather than focusing solely on one potential cause of her symptoms 1.
- By screening for major depressive disorder and considering other potential causes of her symptoms, the patient can receive appropriate treatment and management, which can help to improve her quality of life and reduce her symptoms.
From the Research
Evaluation of the Patient's Condition
The patient presents with a 2-month history of poor sleep, fatigue, and unintentional weight loss, which are common symptoms of major depressive disorder (MDD) 2, 3, 4, 5. The patient's normal TSH levels and negative hCG test results help to rule out other potential causes of her symptoms, such as thyroid dysfunction or pregnancy.
Considerations for Next Steps
Given the patient's symptoms and test results, the most appropriate next step in evaluation would be to screen for major depressive disorder (MDD) 2, 3, 4, 5. This can be done using validated screening tools, such as the Patient Health Questionnaire (PHQ-9) or the Beck Depression Inventory (BDI).
Rationale for Screening for MDD
Screening for MDD is important because it can help identify patients who may be at risk for suicide or other complications of depression 2, 3, 4, 5. Additionally, early diagnosis and treatment of MDD can improve patient outcomes and reduce the risk of long-term disability.
Key Points to Consider
- The patient's symptoms of poor sleep, fatigue, and unintentional weight loss are consistent with MDD 2, 3, 4, 5.
- Normal TSH levels and negative hCG test results help to rule out other potential causes of the patient's symptoms.
- Screening for MDD using validated tools can help identify patients who may be at risk for suicide or other complications of depression.
- Early diagnosis and treatment of MDD can improve patient outcomes and reduce the risk of long-term disability.
Recommended Next Step
Based on the patient's symptoms and test results, the most appropriate next step in evaluation would be to screen for major depressive disorder (MDD) using a validated screening tool, such as the PHQ-9 or BDI 2, 3, 4, 5. This can be done by selecting option E) Screening for major depressive disorder.
Some key points to consider when screening for MDD include:
- Using a validated screening tool, such as the PHQ-9 or BDI 2, 3, 4, 5.
- Assessing the patient's symptoms, including depressed mood, loss of interest in activities, and associated psychological and somatic symptoms 2, 3, 4, 5.
- Evaluating the patient's risk of self-harm, suspected bipolar disorder, psychotic symptoms, substance use, and co-occurring anxiety disorder 2, 3, 4, 5.