PEDERSON · Depression / Anxiety
- Name
- Henryk Pederson
- Age
- 25 years
- Opening statement
- “I have been feeling excessively tired. I wondered if I had a virus?”
You have noticed that you have been more tired than usual for the last 6 months or so. You struggle to feel refreshed, even after a good night’s sleep. It’s now starting to affect your work and studies — you struggle to maintain concentration for anything longer than about half an hour. You’ve tried cutting down on caffeine and although you feel less jittery, it hasn’t really helped much else.
If asked to say more about the tiredness or problem, describe the symptoms as above.
- Tiredness seemed to start around the same time that you broke up with your partner. Also a particularly stressful time at university with lots of exams and coursework deadlines.
- Feeling very stressed all the time and worrying about “anything and everything”. Not really been a “worrier” until recently (last few months). When worried/stressed: tension in shoulders, stomach and legs; sometimes heart racing and breathing faster. No particular trigger; happening more often.
- Sleep is quite poor — takes hours to get off; often broken. Sometimes give up around 4–5 am and go for a walk along the canal.
- Appetite has suffered; sometimes forget to eat or just not hungry. Perhaps lost a couple of kilograms (not significant in your view).
- Not suicidal and no deliberate self-harm. Occasionally wonder if anyone would miss you if you were no longer around, but no plans to harm yourself.
- Regular headaches (2–3 per week) — new for you. Generalised and achy, sometimes worse around the sides, tend to occur towards end of day. Sometimes feel a bit sick but no vomiting or visual changes; lying down can help. Paracetamol seems ineffective but you still take it.
- Bowel habit a bit variable (never completely regular); no rectal bleeding or abdominal pain. Breathing and urination fine.
- If the student/doctor does not acknowledge your ideas (virus) and does not address this concern in their explanation, you will ask again if this could have been caused by a virus.
- Ideas: You think this has all been triggered by a virus.
- Concerns: You worry that it’s affecting your work (need your job to support your studies) and may affect your course grades.
- Expectations: You expect that the GP will organise some blood tests to diagnose a virus.
- Feelings: A bit fed up of feeling this way; worried for your future and hopeful that getting a diagnosis might help you recover and start feeling back to normal. Worried about the increasing episodes of worry which feel overwhelming at times.
- Greenstick fracture of humerus (arm) age 7 years
- Tonsillectomy age 10 years
- Nil regular medication
- Paracetamol for headaches (as required)
- No known drug allergies
- Mother: Hypothyroidism
- Father: Hypertension; obstructive sleep apnoea
- Single, bisexual, no children
- Occupation: Student architect and bar work
- Housing: lives on a barge (eco-friendly; cannot afford “normal” housing rent; likes the freedom and finds the water helps creativity)
- Support system: limited. Parents/family live in Norway. A few friends from the course but busy course + work means limited social time. Has a cousin in London.
- Never smoked
- Alcohol: occasional beer in the week; 1 bottle of wine over the weekend (15–20 units/week)
You are comfortable with your sexuality; parents were a little surprised when you “came out” but have been largely supportive. Never been a recipient of bullying/hate crimes.
The break-up with your girlfriend was inevitable given how busy and therefore detached you were. This upset you and you blame yourself for it. Still in some contact but she has moved on to a new relationship. You have felt too tired to pursue dating currently.
You come across as surprised if depression/anxiety/psychological causes are suggested, however you are not offended or defensive and accept the student/GP’s opinion.
When talking about the episodes of worry/stress and your racing heart rate and breathing you become more visibly on edge and anxious. If this is acknowledged sensitively by the doctor/student you are easy to calm and get back on track. If not acknowledged this continues and escalates.
PMH: Greenstick fracture of humerus age 7; Tonsillectomy age 10
Last consultations:
• February 2020 – URTI, delayed script for amoxicillin, supportive advice
• December 2019 – Sore throat, likely viral, supportive advice/reassured
• April 2018 – Testicular pain (suspected epididymo-orchitis); treated with ciprofloxacin; advised to see GUM for full STI screen
Current medication: Nil regular · No known drug allergies
- BP 126/70
- Pulse 76, regular
- Weight 66 kg · Height 180 cm
- Chest / abdomen / cardiovascular examination normal
Provide copies of PHQ-9 and GAD-7 only if the student asks for them during the consultation. If not requested, discuss their utility in the debrief and (if time) allow the student to return to complete them.
Hand this over only if the student asks for a copy to use during the consultation.
If the student asks you these questions directly, give the circled answer for each one below.
| Over the last 2 weeks, how often have you been bothered by the following problems? | Score |
|---|---|
| 1. Feeling nervous, anxious or on edge | 3 (Nearly every day) |
| 2. Not being able to stop or control worrying | 1 (Several days) |
| 3. Worrying too much about different things | 3 (Nearly every day) |
| 4. Trouble relaxing | 3 (Nearly every day) |
| 5. Being so restless that it is hard to sit still | 1 (Several days) |
| 6. Becoming easily annoyed or irritable | 1 (Several days) |
| 7. Feeling afraid as if something awful might happen | 1 (Several days) |
Total GAD-7 score: 13 (moderate anxiety)
Exact scanned answer sheet, for reference:
Hand this over only if the student asks for a copy to use during the consultation.
If the student asks you these questions directly, give the circled answer for each one below.
| Over the last 2 weeks, how often have you been bothered by any of the following problems? | Score |
|---|---|
| 1. Little interest or pleasure in doing things | 2 (More than half the days) |
| 2. Feeling down, depressed, or hopeless | 1 (Several days) |
| 3. Trouble falling or staying asleep, or sleeping too much | 3 (Nearly every day) |
| 4. Feeling tired or having little energy | 3 (Nearly every day) |
| 5. Poor appetite or overeating | 3 (Nearly every day) |
| 6. Feeling bad about yourself – or that you are a failure or have let yourself or your family down | 1 (Several days) |
| 7. Trouble concentrating on things, such as reading the newspaper or watching television | 3 (Nearly every day) |
| 8. Moving or speaking so slowly that other people could have noticed / being so fidgety or restless | 1 (Several days) |
| 9. Thoughts that you would be better off dead, or of hurting yourself in some way | 0 (Not at all) |
Total PHQ-9 score: 17 (moderately severe depression)
Exact scanned answer sheet, with the full severity scale, for reference:
Students should undertake a relatively simple history pointing to a potential diagnosis of depression/anxiety, wrap up with an initial management plan aligned with current NICE guidelines, and communicate this with the patient (considering concerns, presentation and family history). Discussion of scoring tools and their utility (or not) in primary care is appropriate in the debrief.