History of Present Illness (HPI)
The patient is a 37-year-old female presenting with complaints of anxiety, poor concentration, and depression. She has a past medical history (PMH) of allergies, headaches (HA), and irregular menstrual cycles. Her current treatments include Buspar, which she recently stopped due to unpleasant side effects. She reports difficulty sleeping, occasional positional discomfort when turning her head, and increased congestion with postnasal drip, for which she has been taking cetirizine. She denies suicidal thoughts, recent alcohol or drug use, and any medication side effects.
Differential Diagnosis
- Single Most Likely Diagnosis
- Major Depressive Disorder (MDD): The patient's presentation of depression, anxiety, poor concentration, and sleep disturbances aligns with the diagnostic criteria for MDD. The recent cessation of Buspar, an anxiolytic, could also contribute to her current symptoms.
- Other Likely Diagnoses
- Anxiety Disorder: Given the patient's history of anxiety and current symptoms, an anxiety disorder such as generalized anxiety disorder (GAD) is a plausible diagnosis.
- Allergic Rhinitis: The patient's complaints of increased congestion and postnasal drip, despite taking cetirizine, suggest poorly controlled allergic rhinitis.
- Sleep Disorder: The patient's difficulty sleeping could be indicative of a sleep disorder, such as insomnia, which may be contributing to her depressive and anxiety symptoms.
- Do Not Miss Diagnoses
- Thyroid Disorder: Irregular menstrual cycles and depression can be symptoms of a thyroid disorder, such as hypothyroidism. Although not directly mentioned, it is crucial to rule out this possibility due to its potential impact on mental health and overall well-being.
- Sleep Apnea: The patient's difficulty sleeping and positional discomfort could be indicative of sleep apnea, a condition that requires prompt diagnosis and treatment to prevent serious health complications.
- Cervicogenic Headache: The patient's mention of positional discomfort when turning her head could suggest a cervicogenic headache, which, although not life-threatening, can significantly impact quality of life.
- Rare Diagnoses
- Chronic Fatigue Syndrome: Although less likely, the patient's complaints of poor concentration, sleep disturbances, and depression could be indicative of chronic fatigue syndrome, a condition characterized by persistent fatigue not relieved by rest.
- Temporomandibular Joint (TMJ) Disorder: The patient's positional discomfort when turning her head could, in rare cases, be related to a TMJ disorder, which can cause referred pain and discomfort.