NR601 Week 3 Case Study Paper
NR601 Week 3 Case Study Paper
Total Points Possible: 70
Anxiety and depression are the most common psychiatric problems you will encounter in your primary care practice.
Review this case study
HPI: BT, 50-year-old Caucasian male presents to office with complaints of “no energy and staying in bed all day.” These symptoms have been present for about 4 months and seem worse in the morning. It is hard to get out of bed and get the day started because he does not feel rested when he gets up in the morning. BT reports “deep sadness & heartache over the loss of his wife”. States” I really don’t feel like making plans or going out”. NR601 Week 3 Case Study Paper. He tries to make plans with family or friends once a week, but it can be really exhausting because everyone asks about how he is handling the loss. Reports he also has difficulty completing projects for work, he cannot stay focused anymore. He reports not eating regularly and has lost some weight. BT has been a widower for 10 months. His wife died unexpectedly, she had an MI. His oldest daughter has a 2-year-old daughter, she asked him to babysit a couple of times, which he thought would help with the loneliness, but the care of his granddaughter seems overwhelming at times. Rest, evening walks, & lifting weights 2 days a week help him feel better. At this time, he does not want to do any activities or exercise, it seems like too much effort to get up and go. He has not tried any medications, prescribed or otherwise. He reports drinking a lot of coffee, but that does not seem to help with his energy levels.
Current medications: Tylenol PM about once a week when he can’t sleep, does not help.
PMH: no major illnesses. Immunizations up to date. COVID Vaccinated.
SH: widowed, employed part time as a computer programmer. Drinks 1 beer almost every night. No tobacco use, no illicit drug use. Previously married 25 years ago, reports a passive aggressive, abusive relationship that ended in divorce. The judge gave full custody of his children to his ex-wife. The last time he saw his son was10 years ago. He lives in another stated. He sees his daughter 1-2 times a month. He would like to talk to his son but he is concerned the relationship cannot be repaired because he moved out during the divorce.
FH: Parents are alive and well. Has a daughter 20 and a son 18.
CONSTITUTIONAL: reports weight loss of 4-5 pounds, no fever, chills, or weakness reported. Daily fatigue.
HEENT: Eyes: No visual loss, blurred vision, double vision or yellow sclera. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose or sore throat.
CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations or edema.
RESPIRATORY: No shortness of breath, cough or sputum.
GASTROINTESTINAL: Reports decreased appetite for about 4 months. No nausea, vomiting or diarrhea. No abdominal pain or blood.
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.
GENITOURINARY: no burning on urination.
PSYCHIATRIC: No history of diagnosed depression or anxiety. Reports history feeling very sad and anxious about loss of wife. Sad about not speaking to his son. Did not seek treatment. He started to feel better about the loss of his wife after 6 months but the grief and depression has returned.
ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. No polyuria or polydipsia
ALLERGIES: No history of asthma, hives, eczema or rhinitis.
- Research screening tools for depression and anxiety. Choose one screening tool for depression and one screening tool for anxiety that you feel are appropriate to screen BT.
- Explain in detail why each screening tool was chosen. Include the purpose and time frame of each chosen tool.
- Score BT using both of your chosen screening tools based on the information provided (not all data may be provided, those areas can be scored as not present). Pay close attention to the listed symptom time frame for your chosen assessment tool. In your response include what questions could be scored, and your chosen score. Interpret the score according to the screening tool scoring instructions. Assume that any question topics not mentioned are not a concern at this time.
- Identify your next step for evaluation and treatment for BT. Remember to consider both physical and mental health differential diagnoses when answering this question. (2-3 sentences).
- What medication or treatment is appropriate for BT based on his screening score today? Provide the rationale. Any medications should include the medication class, mechanism of action of the medication and why this medication is appropriate for BT. Include initial prescribing information.
- If the medication works as expected, when should BT expect to start feeling better?
Good writing calls for the limited use of direct quotes. Direct quotes in discussions are to be limited to one short quotation (not to exceed 15 words). The quote must add substantively to the discussion. Points will be deducted under the grammar, syntax, APA category.
Sample Student Approach
Hamilton Depression Rating Scale (HAM-D) and the Beck Anxiety Inventory (BAI) are the screening tools I will be using for this case study.
Rationale for the use of screening tools
Both the HAM-D and BAI are widely used screening tools that are appropriate for the use in a primary care setting. I primarily choose the HAM-D screening tool because the first 17 questions are to be filled out by the patient and the last 4 are to be filled out by the clinician. I like that this screening tool uses the patients rating of their own symptoms as well as a section for the clinicians input. The HAM-D is also very widely used and considered by many the gold standard for measuring the severity of depression (Rohan et al., 2016) The BAI will be used to assess KF because it is brief but thorough and easy for clinicians to use. The BAI is useful in identifying anxiety disorders as well as emotional states such as panic (Piotrowski, 2018).
HAM-D scoring: #1 depressed mood 1 point for sadness because she reports a loss of joy, #7 work and interests 3 points for decreased productivity because she does not does not want to participate in social activities/ yoga/ meditation/ and is having difficulty with projects at work, #12 somatic symptoms-gastrointestinal 1 point for mild symptoms because she has a loss of appetite and weight loss but no abdominal complaints or constipation, #13 somatic symptoms- general 2 points for severe symptoms because she has no energy and feels tired all the time, #16 weight loss 1 point for slight symptoms because she lost 4-5 lbs, #18 diurnal variation 2 points for severe variation because her symptoms are worse in the morning and only slightly improve throughout the day. Her total on this scale would be 10 which indicates mild depression. I feel since information was assumed on many questions her score could be higher than this. NR601 Week 3 Case Study Paper
BAI scoring: I gave KF a 0 for this assessment because she is not reporting or exhibiting any of the items listed on the form. I also attempted to assess KF using the Generalized Anxiety Disorder-7 (GAD-7) screening tool and also gave her a 0. In the interpretation section of the BAI a low score is not necessarily considered good. Low score can be associated with denial, masking symptoms, or detachment. As with the depression screening I feel KFs score could be higher if she filled the questionnaire out herself.
Evaluation and treatment
The physical health diagnosis I would give KF is major depressive disorder. KF has no past medical history so I feel it would be necessary to order a TSH with reflux FT4 to rule of hypothyroidism, BMP to check for electrolyte abnormalities, urine drug screen to check for substance use disorders, Vitamin D/ Vitamin B12/ Folate level to check for vitamin deficiency, and EKG to look for any arrythmias (Hollier, 2018). I would like to prescribe a selective serotonin reuptake inhibitor (SSRI) for KF because this class of medication is considered to be the first-line treatment for depression (Hollier, 2018). I would start KF on citalopram 20 mg PO daily. Citalopram is a SSRI and the mechanism of action of this drug is inhibition of the central nervous systems reuptake of serotonin (Porter, 2018). KF should start to feel better in 4 weeks but it could take 8-12 weeks for the full response to be noted for this medication (Porter, 2018). This medication is appropriate for KF because SSRIs have the greatest rate for remission of depression as well as the fewer side effects than other classes of antidepressant (Hollier, 2018). Some common side effects of this medication include nausea, dry mouth, tremors, constipation/diarrhea, and common cold symptoms (Porter, 2018). I would schedule KF for a follow-up visit in 1 week and strongly urge her to return sooner if she notices worsening of symptoms or has any other concerns. I would give KF referral information to a behavioral health specialist because medications alone will not effectively manage her depression.
Dr. C and class,
SSRIs are considered first line treatment for depression because they have a higher success rate and tend to have fewer unwanted side effects than other antidepressants. At this time there is a great deal of debate about the safety of prescribing this class of medication to children and adolescents. The literature is conflicting as some recommend this practice while other express caution. This conflicting information has led to uncertainty in practitioners on appropriate treatment of pediatrics with psychiatric disorders. In a recent systematic review of research studies findings indicated that treatment of pediatric patients with SSRIs for common psychiatric disorders was more beneficial than treatment with a placebo (Locher, Koechlin, & Zion, 2017). While this information is positive the study also found that there was also an increase in treatment of emergent situations such as suicidal thoughts and attempts in this population while taking SSRIs (Locher et al., 2017). This risk does not exclude this patient population from being treated with this class of medication, but it does require the practitioner to proceed with caution when prescribing. NR601 Week 3 Case Study Paper
Hollier, A. (2018). Clinical guidelines in primary care (3rd ed.). Lafayette, LA: Advance Practice Education Associates, Inc.
Locher, C., Koechlin, H., & Zion, S. R. (2017). Efficacy and safety of selective serotonin reuptake inhibitors, Sserotonin-norepinephrine reuptake inhibitors, and placebo for common psychiatric disorders among children and adolescents. JAMA psychiatry, 74(10), 1011-1020. http://dx.doi.org/1011-1020. doi:10.1001/jamapsychiatry.2017.2432
Locher, C., Koechlin, H., Zion, S. R., Werner, C., Pine, D. S., Kirsch, I., … Kossowsky, J. (2017). Efficacy and safety of selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, and placebo for common psychiatric disorders among children and adolescents. JAMA Psychiatry, 74(10), 1011-0120. http://dx.doi.org/10.1001/jamapsychiatry.2017.2432
Piotrowski, C. (2018). The status of the Beck inventories (BDI, BAI) in psychology training and practice: A major shift in clinical acceptance. Journal of Applied Biobehavioral Research, 23(3). http://dx.doi.org/10.1111/jabr.12112
Porter, R. S. (2018). Merck Manual of Diagnosis and Therapy (20th ed.). Retrieved from https://www.merckmanuals.com/professional/resources/brand-names-of-some- commonly-used-drugs
Rohan, K. J., Rough, J. N., Evans, M., Ho, S., Meyerhoff, J., Roberts, L. M., & Vacek, P. M. (2016). A protocol for the Hamilton Rating Scale for Depression: Item scoring rules, rater training, and outcome accuracy with data on its application in a clinical trial. Journal of Affective Disorders, 200, 111-118. http://dx.doi.org/10.1016/j.jad.2016.01.051