[45F] Experiencing chronic pain, severe fatigue, and mental health concerns

Depression and Anxiety

Differential diagnosis

• Major depressive disorder, recurrent, moderate (F33.1)
• Generalized anxiety disorder (F41.1)
• Adjustment disorder with mixed anxiety and depressed mood (F43.22)

Plan

Continue current treatment with Bupropion and Trazodone. Consider referral to a psychiatrist for further evaluation and management. Cognitive behavioral therapy (CBT) may be beneficial. Encourage regular exercise, a healthy diet, and good sleep hygiene.

Chronic Pain

Differential diagnosis

• Fibromyalgia (M79.7)
• Chronic pain syndrome (G89.4)
• Myofascial pain syndrome (M79.1)

Plan

Perform a physical exam to assess tender points, joint mobility, and muscle strength. Consider ordering lab tests to rule out other conditions that could cause similar symptoms (e.g., rheumatoid arthritis, lupus). If fibromyalgia is suspected, consider referral to a rheumatologist. Non-pharmacological interventions such as physical therapy, cognitive behavioral therapy, and stress management techniques should be considered.

Irritable Bowel Syndrome (IBS)

Differential diagnosis

• Irritable bowel syndrome with mixed bowel habits (K58.9)
• Functional diarrhea (K59.1)
• Other specified functional intestinal disorders (K59.8)

Plan

Encourage a diet high in fiber and low in gas-producing foods. Consider a trial of a medication such as a tricyclic antidepressant or a selective serotonin reuptake inhibitor (SSRI) for symptom management. If symptoms persist, consider referral to a gastroenterologist for further evaluation and management.

Hypothyroidism

Differential diagnosis

• Hypothyroidism, unspecified (E03.9)
• Other specified disorders of thyroid (E07.8)

Plan

Continue current treatment with Levothyroxine. Monitor thyroid function tests regularly to ensure adequate control. Encourage regular follow-up visits to monitor symptoms and adjust medication dosage as needed.