Depression and COVID-19: Identifying and Treating in the Primary Care Setting

A 35-year-old woman presents with depressed mood, fatigue, lack of interest in activities for the last 6 months after having COVID-19.

Depression was reported in 23% of patients 1 year after COVID-19 infection.

A35-year-old woman presents to a primary care o ce complaining of depressed mood daily, some anxiety but not daily, not sleeping well, and overeating when she is “stressed.” She reports that she is not interacting much with friends and family and has not been exercising as she has in the past. The patient is a nurse in a medical-surgical unit at an urban hospital and has been caring for patients with COVID-19 over the last 2 years. She also reports having COVID-19 approximately 7 months ago. She was able to isolate and manage her symptoms on an outpatient basis.

The patient reports having had depressive symptoms in the past and that the symptoms decreased over time but returned over the last 6 months. She has been attending weekly individual therapy with a social worker for the last 6 weeks with minimal improvement. In the past, her symptoms were e ectively treated with paroxetine, but she gained weight and does not want to restart this agent. She also notes having trouble falling asleep and not feeling rested in the morning. She sleeps approximately 5 hours per night.

Her medical history is signi cant for hyperlipidemia; she does not currently take a lipidlowering medication. Her family history includes a mother with bipolar disorder (diagnosed at age 39 years) and sister with depression (diagnosed at age 28 years). No family history of suicide ideation or completion is reported.

Continues on page 8

MENTAL HEALTH AND COVID-19 The prevalence of depressive disorder was 4 times higher in the first 2 quarters of 2022 compared with the second quarter of 2019.

Laboratory results are normal and do not show any abnormalities that may explain the current symptoms (Table 1).

Mental Status Examination

The patient is appropriately dressed and her body mass index falls in the overweight but not obese category. Her thoughts are organized and logical. She denies any hallucinations and does not appear to be attending to internal stimuli currently. She does not verbalize anything that could be considered delusional. She reports depressive symptoms for the last 6 months.

She describes her mood as sad and reports she is much more tearful than she has been in the past. She reports an increase in irritability and being easily frustrated. The patient appears to have a depressed mood. She is going to work as scheduled but then comes home and isolates herself until bedtime. She is not interacting much with her family or friends and has been declining invitations. She reports somatic complaints such as headaches and stomachaches and uses these somatic complaints to avoid doing things. She reports anxiety at times, typically when someone is trying to get her to do something she does not want to do.

She denies suicidal and homicidal ideations and has not had these thoughts in the past. She denies any past hypomania or mania after being educated on the symptoms of these conditions and denies any current or past substance abuse. Her attention and judgment are intact and her speech is normal tone and rate, with no pressured speech. Her insight on depression is fair and she will benefit from additional education regarding disease process. The patient scored a 15 on the Patient Health Questionnaire (PHQ-9). She is diagnosed with recurrent major depressive disorder of moderate severity.

Discussion

The COVID-19 pandemic has had a severe effect on the mental health of people in the US and globally. In the first year of the COVID-19 pandemic, the prevalence of anxiety and depression increased by 25%, according to the World Health Organization.1

In 2020, an estimated 21.0 million US adults (or 8.4% of all US adults) had at least 1 major depressive episode.2 In approximately 14.8 million episodes, the impairment was severe. The prevalence of depressive disorder was approximately 4 times high in the first 2 quarters of 2022 compared to the second quarter of 2019 (24.3% vs 6.5%), according to findings from the Centers for Disease Control and Prevention (CDC).3 Although concern was raised that these numbers may have been exaggerated by the study method and the symptoms were not lasting, evidence suggests that the rate of depressive disorders increased with the onset of the COVID-19 pandemic.3

Data from the Household Pulse Survey conducted by the National Center for Health Statistics and the US Census Bureau (June 9-July 11, 2022) shows that 10% to 37% of Americans report symptoms of depressive disorder, with those aged 18 to 29 years showing the highest rates (Figure).4

In some cases, depression may be the result of isolation and increased stress faced during the COVID-pandemic. Research also suggests that depression is one of the many symptoms of long COVID.5

In a systematic review and meta-analysis of 1-year followup data from 8591 patients with COVID-19, depression was

TABLE 1. Laboratory Results

Test Results

Complete blood cell count Normal

Comprehensive metabolic count Normal except hyperlipidemia: • LDL: 175 mg/dL • HDL: 32 mg/dL • Triglycerides: 202 mg/dL

Pregnancy test Negative

Thyrotropin 2.32 μU/mL (Normal range: 0.5-4.0)

Triiodothyronine and free thyroxine needed if thyrotropin is abnormal N/A

Urine drug screen Negative

Vital signs • Blood pressure: 124/76 mm Hg • Respiratory rate: 18 bpm • Pulse: 84 bpm • Temperature: 97.7 ºF

bpm, beats per minute; HDL, high-density lipoprotein; LDL, low-density lipoprotein

If a patient is having suicidal ideation with a viable plan, a safety plan must be made before the patient leaves the office.

reported in 23%.6 In an observational study of 273 patients in India, 12% of patients developed depressive symptoms immediately (14-21 days) after a positive COVID-19 test and 5% of patients developed depressive symptoms approximately 3 months (90-97 days) after a positive test.7 A greater number of COVID-19 symptoms at the time of diagnosis and comorbid diabetes mellitus were associated with a greater risk for depression.7

Diagnosing Depression

The patient interview is an important element of the initial assessment for depression and should include patient history as well as current medical and mental status (Table 2, page 10).8 Assessment tools include the PHQ-2 and PHQ-9 for depressive symptoms, Columbia Suicide Severity Rating Scale for suicidal ideations and intent, Generalized Anxiety Disorder 7-item Scale (GAD-7) for anxiety, and CAGE for alcohol use disorder.9-12

When asking patients about sleep, it is important to clarify what “not sleeping well” means to the patient. Does she have trouble falling asleep, staying asleep, or both? What time does she go to bed? What time does she normally gets out of bed in the morning? Does she take any over-thecounter or prescribed medications for sleep or has she in the past? Does she drink alcohol or use any other substances to help her sleep? Does she have a history of sleep apnea? If so, is she following the recommendations for sleep apnea treatment?

It is always important to assess for thoughts of suicide and past suicide attempts or thoughts. If a patient presents with suicidal ideation, ask if the patient has a plan. If the patient is actively having suicidal ideation with a viable plan, a safety plan must be made before the patient leaves the office. This may mean a transfer to an inpatient facility, so it is important to have a plan in advance. Is it appropriate to call 911, is there security in the building, and what are the policies to commit a patient against their will? It is important to have these details understood prior to an emergency. If a patient is not actively suicidal, has community resources, agrees to continue outpatient treatment, has family or social support, and does not verbalize intent then the patient may be treated on an outpatient basis.

In adults, the differential diagnosis should include hypothyroidism or hyperthyroidism; anemia; bipolar disorder and current episode depressed; and adjustment disorder with depressed mood. Routine laboratory studies should be completed to rule out hypothyroidism and any other medical conditions that could explain the current symptoms. Common symptoms of hypothyroidism are fatigue, depression, and weight gain.13 Common symptoms of hyperthyroidism

Depressive Symptoms, %

40

35

30

25

20

15

10

5

0 36.9

27.7

25.3

22.8

15.8

11.8 9.6

18-29 years 30-39 years 40-49 years 50-59 years 60-69 years 70-79 years 80+ years

Source: National Center for Health Statistics4

FIGURE. Percentage of respondents to the Household Pulse Survey reporting symptoms of depression during the past 2 weeks by age.

TABLE 2. Signs and Symptoms of Major Depressive Disorder 8

Decreased interest in normal activities

Decreased concentration

Depressed mood

Fatigue

Feelings of worthlessness

Inappropriate guilt

Insomnia or hypersomnia

Psychomotor agitation or retardation

Recurrent thoughts of death and/or suicidal ideation

Significant unintentional weight loss

TABLE 3. Signs and Symptoms of Hypomania and/or Mania8

Decreased sleep or need to sleep

Elevated, expansive, or irritable mood

Flight of ideas or racing thoughts

Grandiosity

Hyperverbal or pressured speech

Increased activity in general

Increased risky behavior such as overspending, sexual indiscretions, or poor financial decisions

Poor concentration

Symptoms need to be present for at least 1 week and present most of the day to meet the criteria for mania Symptoms need to be present for at least 4 consecutive days for most of the day to meet the criteria for hypomania

TABLE 4. Medications Used to Treat Depression Among Adults in Primary Care

SSRIs SNRIs

Citalopram

Escitalopram

Fluoxetine

Fluvoxamine Desvenlafaxine

Duloxetine

Levomilnacipran

Venlafaxine

Paroxetine

Sertraline

SNRIs, serotonin and norepinephrine reuptake inhibitors; SSRIs, selective serotonin reuptake inhibitors are increased anxiety, weight loss, and fatigue.14 Fatigue from anemia can be confused as depressive symptoms. Complete metabolic panel needs to be completed to rule out any electrolyte imbalances.

It is imperative to assess for any history of hypomania or mania (Table 3).8 Patients may have a history of bipolar disorder or an undiagnosed bipolar disorder and present with depressive symptoms. It is possible to induce mania or hypomania if an antidepressant is initiated in such patients.

Treatment of Depression

The American Psychological Association (APA) recommends that clinicians offer either psychotherapy or second-generation antidepressants as the first-line treatment of depression; a combination of these 2 strategies may also be used.15 Several medications are available for the treatment of depression in the primary care setting (Table 4).

The case patient had a positive response to paroxetine in the past but had significant weight gain. The patient should respond well to the other selective serotonin reuptake inhibitors (SSRI). She could also benefit from a serotoninnorepinephrine reuptake inhibitor (SNRI). Both SSRIs and SNRIs can decrease depressive symptoms as well as anxiety. Several SSRIs are weight neutral including fluoxetine, escitalopram, and sertraline.16

Nonpharmacologic Treatments for Adults With Depression

Effectiveness studies have shown similar effects across various forms of psychotherapy used to treat depression and the APA does not recommend one form over another.15 General models recommended by the APA include: • Behavioral therapy • Cognitive behavioral therapy (CBT) and mindfulness-based cognitive therapy • Interpersonal psychotherapy • Psychodynamic therapies • Supportive therapy

Cognitive behavioral therapy has been found to be as effective as medication in some cases. The focus of CBT is to change distorted thinking. Cognitive behavioral therapy improves a person’s mood by teaching appropriate and healthy coping mechanisms, increasing self-confidence, addressing fears instead of avoidance, and teaching patients to manage their stress independent of the therapist.17

Follow-up and Discussion

The patient continued with weekly individual therapy with a social worker and was initiated on fluoxetine 10 mg once

daily taken in the morning. She is asked to return to the clinic in 2 to 4 weeks.

At the follow-up appointment, the clinicians should assess for effectiveness of medication, current mental status, suicidal ideation, and sleep pattern. If the patient is not having any adverse effects from the selected medication but is still reporting symptoms, the medication dose can be increased until symptoms resolve or the patient has adverse effects.

If the patient cannot tolerate the first medication option, it is appropriate to change to another agent in the same class. If the patient fails 2 agents in the same class, it is appropriate to change to another class of medication such as an SNRI.18

Conclusion

The rising rates of depression stemming from the COVID-19 pandemic remain a major burden to overcome in the primary care setting. Screening for depressive symptoms can be part of the initial intake and subsequent visits in primary care. Education regarding the signs and symptoms of depression may be needed as people may not recognize their symptoms as those of depression.

Patients may present with insomnia and not verbalize that they are feeling more irritable or have been isolating. Primary care providers can provide appropriate treatment including prescribing medication, referrals to a therapist, or in some cases referral to a mental health provider.

The pandemic led many patients to be neglectful of regular medical appointments. Now, these patients may be seeking treatment for the first time in 2 years. Being alert to possible symptoms associated with depression in all patients will help improve overall care. ■

Christy Cook-Perry, DNP, PMHNP, ANP, is an assistant professor at Southeastern Louisiana University College of Nursing and Health Sciences. Jennifer Allain, DNP, MSN, APRN, FNP-C, is the NP program coordinator and master teacher of mental health psychiatric nursing at The LHC Group, Myers School of Nursing of the University of Louisiana at Lafayette College of Nursing and Health Sciences. Shirley Griffey, DNP, PMHNP, is a psychiatric nurse practitioner at Baton Rouge General Medical Center and an instructor at Southeastern Louisiana University School of Nursing in Baton Rouge, Louisiana.

References

1. World Health Organization. Mental Health and COVID-19: Early evidence of the pandemic’s impact. Scientific brief. March 2, 2022. Accessed July 19, 2022. https://www.who.int/publications/i/item/ WHO-2019-nCoV-Sci_Brief-Mental_health-2022.1 2. Major depression. National Institute of Mental Health. Updated January 2022. Accessed July 20, 2022. https://www.nimh.nih.gov/health/statistics/ major-depression 3. Czeisler MÉ, Lane RI, Petrosky E, et al. Mental health, substance use, and suicidal ideation during the COVID-19 pandemic - United States, June 24-30, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(32):1049-1057. 4. Household Pulse Survey — anxiety and depression. Centers for Disease Control and Prevention, National Center for Health Statistics. Accessed August 1, 2022. http://www.cdc.gov/nchs/covid19/pulse/mentalhealth.htm 5. Centers for Disease Control and Prevention. Evaluating and caring for patients with post-covid conditions: interim guidance. Updated June 2021. Accessed April 28, 2022. https://www.cdc.gov/coronavirus/ 2019-ncov/hcp/clinical-care/post-covid-workup.html 6. Han Q, Zheng B, Daines L, Sheikh A. Long-term sequelae of COVID-19: a systematic review and meta-analysis of one-year follow-up studies on post-COVID symptoms. Pathogens. 2022;11(2):269. 7. Shah A, Bhattad D. Immediate and short-term prevalence of depression in COVID-19 patients and its correlation with continued symptoms experience. Indian J Psych. 2022;64(3):301-306. 8. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed, text revision. American Psychiatric Association; 2022. 9. Patient health questionnaire-9 (PHQ-9). Accessed July 20, 2022. https://www.apa.org/depression-guideline/patient-health-questionnaire.pdf 10. Interian A, Chesin M, Kline A, et al. Use of the Columbia-Suicide Severity Rating Scale (C-SSRS) to classify suicidal behaviors. Arch Suicide Res. 2018;22(2):278-294. 11. Spitzer RL, Kroenke K, Williams JB, Löwe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006; 166(10):1092-1097. 12. CAGE substance abuse screening tool. Johns Hopkins Medicine. Accessed July 2, 2022. https://www.hopkinsmedicine.org/johns_hopkins_healthcare/ downloads/all_plans/CAGE%20Substance%20Screening%20Tool.pdf. 13. Hypothyroidism (underactive thyroid). Mayo Clinic. November 19, 2020. Accessed July 20, 2022. https://www.mayoclinic.org/diseases-conditions/ hypothyroidism/symptoms-causes/syc-20350284 14. Hyperthyroidism (overactive thyroid). Mayo Clinic. Accessed July 20, 2022. https://www.mayoclinic.org/diseases-conditions/hyperthyroidism/ symptoms-causes/syc-20373659 15. Guideline Development Panel for the Treatment of Depressive Disorders. Summary of the clinical practice guideline for the treatment of depression across three age cohorts. Am Psychol. 2021 Nov 29. 16. Gill H, Gill B, El-Halabi S, et al. Antidepressant medications and weight change: a narrative review. Obesity (Silver Spring). 2020;28(11): 2064-2072. 17. What is cognitive behavioral therapy? American Psychology Association. July 2017. Accessed July 23, 2022. https://www.apa.org/ptsd-guideline/ patients-and-families/cognitive-behavioral 18. Gelenberg AJ, Freeman MP, Rosenbaum J, et al. Practice guideline for the treatment of patients with major depressive disorder, 3rd Edition. American Psychiatric Association: 2010. https://psychiatryonline. org/pb/assets/raw/sitewide/practice_guidelines/guidelines/mdd.pdf

Salary Survey 2022: How Do You Compare to Your Peers?

The results from the ClinicalAdvisor 2022 Salary Survey are in. The good news is that many nurse practitioners (NPs) and PAs earned a higher salary this year compared with last year (48.6% and 38.9%, respectively), and nearly half of NPs and PAs reported that their income increased during the COVID-19 pandemic (49.5% and 40.4%, respectively). The average salary for NPs in 2022 was $117,054 compared with $112,979 last year. The average salary for PAs increased by $8,000, from $116,373 in 2021 to $124,182 in 2022.

The bad news is that 2.5 years into the COVID-19 pandemic, a large proportion of NPs and PAs reported experiencing burnout (66.2% and 62.6%, respectively). Work-related stress is a major contributor to burnout, with 41.4% of NPs reporting moderate stress, 35.6% high stress, and 15.1% extremely high stress. The picture is similar for PAs, with 41.7% experiencing moderate stress, 36.3% high stress, and 12.0% extremely high stress.

Although internal medicine/family medicine/primary care

Results of remains the top occupation for NPs and PAs, 2022 the number of clinicians working in this eld continues to decline as clinicians subCLINICAL ADVISOR specialize. Last year, approximately 23.7% of NPs and 11.9% of PAs reported working in internal medicine/family medicine/ NP/PA primary care and that percentage dropped to 15.4% of NPs and just 7.3% of PAs. For SALARY NPs, the next most common area of practice SURVEY was adult care (8.8%); for PAs, orthopedic surgery came in second (5.8%). Again this year, the majority of NP and PA respondents reported working in the South (37.9% and 32.6%, respectively). Similar to the ndings from the 2021 survey, both NPs and PAs in the West reported making the highest average salaries ($130,410 and $128.137) (see Figures). Most NPs reported working in urban areas (41.7%), followed closely by suburban areas (35.7%). For PAs, most respondents reported working in suburban areas (44.7%) with urban areas following closely behind (41.8%).

West

16.3% (n=152)

$130,410

average salary

Midwest

25.3% (n=235)

$111,150

average salary

Northeast

20.4% (n=189)

$121,678

average salary

West

25.3% (n= 69)

$128,137

average salary

Midwest

18.7% (n=51)

$126,500

average salary

Northeast

23.4% (n= 64)

$123,393

average salary

South

37.9% (n=352)

$113,582

average salary

South

32.6% (n=89)

$120,607

average salary

FIGURE 1. Average NP salary by geographic region FIGURE 2. Average PA salary by geographic region

For a full recap of the 2022 Salary Survey, please visit ClinicalAdvisor.com/SalarySurvey2022.

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Depression Screening Increased in Primary Care

DEPRESSION screening increased after implementation of a general screening program in 2017, according to study findings published online in JAMA Network Open.

Maria E. Garcia, MD, MPH, from the University of California in San Francisco, and colleagues examined depression screening rates among populations at risk for undertreatment of depression in electronic record data from 52,944 adults at 6 primary care facilities from September 1, 2017, to December 31, 2019. Depression screening rates were assessed after implementation of a general screening policy.

The researchers observed an increase in depression screening from 40.5% at rollout in 2017 to 88.8% in 2019. The likelihood of being screened decreased with increasing age in 2018 (adjusted odds ratios: 0.89 and 0.75 for ages 45 to 54 years and 75 years and older, respectively, vs 18 to 30 years). Patients with limited English proficiency, except for Spanish-speaking patients, were less likely to be screened for depression than English-speaking White patients (adjusted odds ratios: 0.59 and 0.55 for Chinese language preference and other non-English preferences, respectively). Depression screening rates increased for all at-risk groups by 2019 and disparities disappeared for most; lower odds of screening were still seen for men vs women (adjusted odds ratio: 0.87).

“Given well-documented depression care disparities for men, racial and ethnic minority individuals, patients with language barriers, older patients, and patients with public insurance, a focus on implementing depression screening and initial depression treatment in primary care may help to improve depression recognition and appropriate treatment for all patients,” the authors wrote.

Depression screening increased among racial minorities after start of program.

Beneficial Effects of Salt Substitutes on Blood Pressure

THE BENEFICIAL effects of salt substitutes on blood pressure were consistent across geographies and populations, according to a review published online in Heart.

Xuejun Yin, from the George Institute for Global Health at the University of New South Wales in Newtown, Australia, and colleagues conducted a systematic review to examine the effects of salt substitutes on outcomes to understand the likely generalizability of the results of the Salt Substitute and Stroke Study, which reported blood pressure-mediated benefits of a potassium-enriched salt substitute. Data were included from 21 trials with 31,949 participants; 19 reported effects on blood pressure, and 5 reported effects on clinical outcomes. The overall reduction of systolic and diastolic blood pressure was -4.61 and -1.61 mm Hg, respectively. Consistent reductions in blood pressure were seen across geographical regions and population subgroups defined by age, sex, hypertension history, body mass index, baseline blood pressure, and baseline 24-hour urinary sodium and potassium. Each 10% lower proportion of sodium chloride in the salt substitute was associated with -1.53 and -0.95 mm Hg greater reduction in systolic and diastolic blood pressure, respectively. Protective effects were seen for salt substitutes on total mortality, cardiovascular mortality, and cardiovascular events (risk ratios, 0.89, 0.87, and 0.89, respectively).

“These findings are unlikely to reflect the play of chance and support the adoption of salt substitutes in clinical practice and public health policy as a strategy to reduce dietary sodium intake, increase dietary potassium intake, lower blood pressure, and prevent major cardiovascular events,” the authors wrote.

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Appendectomy vs Antibiotics: Which Is Best for Acute Appendicitis?

Antibiotics may be preferred over surgery in uncomplicated appendicitis.

FOR ACUTE uncomplicated appendicitis, is nonoperative management with antibiotics as safe as surgery? When nonoperative management is compared with appendectomy, treatment success or likelihood of major complications are similar, according to findings published in JAMA Surgery. However, nonoperative management is linked to a longer length of hospital stay and a higher rate of recurrent appendicitis compared with appendectomy.

The findings are based on a systematic review and meta-analysis of 8 randomized clinical trials. The primary outcome was treatment success at 30 days (or the longest period of follow-up when different time points were reported) as defined in the individual trials, which included resolution of abdominal pain, no complications, and improvement of inflammatory markers.

Previous studies have shown that antibiotic treatment of appendicitis is a safe alternative to appendectomy; however, a wide range of treatment failure rates (7% to 39%) was found with nonoperative management.

The overall risk ratio (RR) for successful treatment of appendicitis at follow-up did not differ between the antibiotic group and the appendectomy group (0.85; 95% CI, 0.66-1.11). Six of the 8 trials did not find statistically significant differences in the primary outcome between the antibiotic and appendectomy groups. One study reported a statistically significant benefit with surgical treatment, while another showed that antibiotic treatment was superior to appendectomy.

A meta-analysis of the 6 trials that reported rates of major adverse effects at 30 days showed that antibiotic treatment was associated with a nonsignificant trend toward lower rates of major adverse effects compared with appendectomy (RR, 0.72; 95% CI, 0.29-1.79). One study reported significant superiority of antibiotic treatment, while another reported superiority of operative treatment. The other 4 trials showed no statistically significant difference in major adverse effects between the groups. Mortality was low in both groups and across trials.

In a meta-analysis of findings from the 3 trials that reported total hospital length of stay, operative treatment was associated with a significantly shorter length of hospital stay (RR, 1.48; 95% CI, 1.26-1.70).

According to data from the largest trial in the meta-analysis, the CODA collaborative trial (N=1552), the median rate of rehospitalization for appendicitis was 18%.

The study authors emphasized the need to consider local infrastructure conditions when selecting antibiotic treatment and for close monitoring of patients using serial physical examinations and round-the-clock availability of imaging, interventional radiology, laboratory testing, and rehospitalization, as well as the flexibility to change treatment approach if needed.

Higher ADHD Scores Seen for Children Born Early Term

CHILDREN WITH early-term birth have increased hyperactivity scores and attention-deficit/hyperactivity disorder (ADHD) scores, according to study findings published online in The Journal of Pediatrics.

Researchers examined the associations between gestational age and teacher-reported ADHD-related symptom patterns at age 9 years in a secondary analysis involving approximately 1400 children in the Fragile Families and Child Wellbeing study born at term (37 to 41 weeks). Teachers evaluated their students at age 9 years using the Conners Teacher Rating Scale-Revised Short Form that included subscales for symptoms of hyperactivity, ADHD, oppositional behavior, and cognitive problems/ inattention, noted Geethanjali Lingasubramanian, MD, from Rutgers University in New Brunswick, New Jersey, and colleagues.

Each week of gestational age at term was associated with lower hyperactivity scores, ADHD scores, and cognitive problems/inattention scores (adjusted incidence rate ratios [IRR]: 0.94, 0.95, and 0.95, respectively). Increased hyperactivity scores and ADHD scores were seen in association with early-term birth (37 to 38 weeks) compared with birth at 39 to 41 weeks (adjusted IRR: 1.23 and 1.17, respectively) as well as an increase in the odds of scoring 1.5+ standard deviations above the sample mean for hyperactivity (adjusted odds ratio: 1.51). No significant associations were seen between gestational age and oppositional behavior scores. ■

Unusual Cause of Chest, Abdominal Pain in Teen Following ACL Repair

The patient has a history of Helicobacter pylori infection, anterior cruciate ligament tear, and stress fracture of the right tibia.

© IGOR VERSHINSKY / GETTY IMAGES

Patient’s vitals are notable for tachycardia and hypertension.

A17-year-old Black woman presents to a family medicine clinic with a 1-day history of acute-onset chest discomfort, palpitations, and abdominal pain. The patient denies aggravating or alleviating factors as well as shortness of breath, activity intolerance, hematemesis, or melena. Two weeks prior, she was prescribed naproxen 500 mg twice daily for knee pain that was precipitated by squatting exercises at physical therapy (PT). She was completing PT after a right anterior cruciate ligament (ACL) repair several months prior. The family medicine provider who prescribed naproxen instructed her to take it with food and to avoid all other nonsteroidal anti-in ammatory drugs (NSAIDs). She was not taking any other known gastric mucosa irritants.

Since sustaining the ACL tear, the patient took 3 sepa rate courses of ibuprofen and naproxen without incident. She experienced improved mobility and denied any additional trauma to the right knee. Up until the PT visit, the patient had been well managed with nonpharmacologic pain treatments. The care for this patient occurred over several visits; a timeline of the progression of care is shown in Figure (page 20).

History

The patient is a refugee from South Sudan and moved to the United States in 2017. She is currently enrolled at a local high school. She denies alcohol, tobacco, or drug use and is not participating in any organized sports. The patient has

regular menstrual cycles that last 5 to 6 days and are moderately heavy for 2 to 3 days.

The patient’s medical history includes Helicobacter pylori infection, an isolated episode of syncope with negative cardiology workup, ACL tear of the right knee, and stress fracture of the right tibia. Her medical history is limited by lack of documentation prior to 2017. Her family history is notable for maternal hypertension and diabetes. The patient has no known coagulation disorders, liver disease, or other chronic conditions.

Physical Examination

Physical examination findings are normal except for tachycardia (112 beats/min) and hypertension (142/82 mm Hg and 134/74 mm Hg upon recheck); other vital signs are stable. Abdominal examination is normal with active bowel sounds, no tenderness to palpation, guarding, rigidity, organomegaly, masses, or costovertebral angle tenderness. Blood work for complete blood cell count (CBC) and comprehensive metabolic panel (CMP) is taken and electrocardiography is ordered.

The patient is instructed to discontinue naproxen immediately and begin omeprazole 20 mg once daily. She is scheduled for a follow-up visit in 5 days to discuss the laboratory results.

Laboratory Evaluation and Follow-Up Visit

Findings from CBC show various abnormalities consistent with anemia (Table 1). Her CMP results are within normal limits except for a glucose level of 103 mg/dL and carbon dioxide of 19 mmol/L. The patient did not present to the local medical center to have the electrocardiography completed.

During the first follow-up visit, the patient denies symptoms; however, when a more specific review of systems is taken, the patient notes exercise intolerance and shortness of breath when participating in her physical education class. She also experiences dizziness that she attributes to not “drinking enough water.” The patient has improved abdominal pain following naproxen discontinuation. Currently, she is not experiencing syncope or near syncope, appetite changes, sleep changes, nose bleeds, melena, or hematuria. However, she does report melena associated with episodes of abdominal pain earlier in the week.

Her vitals are somewhat improved with a heart rate of 98 beats per minute and blood pressure of 128/72 mm Hg; other vital signs are stable. A physical examination reveals generalized abdominal tenderness and is otherwise normal with no tachycardia, respiratory abnormalities, organomegaly, or changes to bowel sounds. Because of the patient’s recent hemoglobin of 9.0 g/dL, blood work is ordered to recheck CBC and evaluate iron studies including ferritin, iron, total iron binding capacity (TIBC), and reticulocyte count (Table 2). Fecal occult studies, H pylori antibodies, and hematopathology smear review are also ordered (Table 3).

The differential diagnosis includes gastrointestinal (GI) bleed, peptic ulcer disease, H pylori infection, acute gastritis, coagulopathy, and angiodysplasia. Considering the recent naproxen use and anemia, omeprazole 20 mg daily is continued to treat acute gastritis and suspected GI bleeding.

Treatment

The day 5 laboratory evaluation confirms that the patient has anemia. The patient’s low mean corpuscular volume (MCV) indicates smaller than usual red blood cell (RBC) size and low mean corpuscular hemoglobin concentration (MCHC) indicates decreased hemoglobin concentration within the RBC (Table 2).

2/15

• ACL tear previously repaired • Pain in knee exacerbated by PT • Starts naproxen 500 mg twice daily for 14 days

2/28

• Chest pain • Palpatations • Abdominal discomfort

3/1

• CBC and

CMP ordered • Stops naproxen • Starts omeprazole 20 mg daily

3/5

• CBC and iron studies • Hematopathology smear review • Fecal occult blood • H pylori testing • Pediatric GI referral • Continue omeprazole

3/10

• Starts ferrous sulfate 325 mg daily

3/17

• Pediatric GI evaluation • Symptoms improved • CBC improving • Omeprazole increased to 40 mg daily • Continue ferrous sulfate

4/28

• CBC improving • Continue ferrous sulfate

ACL, anterior cruciate ligament; CBC, complete blood cell count; CMP, comprehensive metabolic panel; GI, gastroenterology; H pylori, Helicobacter pylori

FIGURE. Timeline of health care visits.

10/20

• Well adolescent visit • CBC stable • Improved iron studies • Continued iron-deficiency anemia • Continue ferrous sulfate