Write a Respond to two of these #1&2 case studies using one or more of the following approaches:
Response # 1
“The case of physician do not heal thyself”
Three questions I will ask the patient on a visit to my office and rationale thereof.
Major depressive disorder (MDD) is defined as “feelings of sadness and/or a loss of interest in activities once enjoyed. It can lead to a variety of emotional and physical problems and can decrease a person’s ability to function at work and at home” and it is one of the most common reasons patients present for medical care worldwide (McConnell, Carter & Patterson, 2019). Childhood traumatic experiences, including physical, sexual, and emotional abuse, neglect, and separation from caregivers, they posit significantly increase the risk of developing mental and physical illnesses later in life.
Have you had any thoughts of death or suicide before? Are you having them now? And do you have a current plan to harm or kill yourself? What are the details of that plan?
McConnell,et .al, (2019) posit that clients with MDD often presents with feeling sad or depressed; lack of interest or pleasure in previously enjoyed activities; appetite changes (unintentional weight loss or gain); sleep difficulty (too much or little); lack of energy (fatigue); feeling of guiltiness or worthlessness; moving more slowly or pacing (others observe); difficulty with decision-making, concentration, and thinking; and/or suicidal thoughts.
Patient safety remains a central concern in every healthcare setting (Smith,2018). This patient did report several feelings of Suicide Ideation and Homicidal ideation so patients’ safety should be priority. Although the welfare of patients encompasses a broad range of concerns, the increasing prevalence of suicide in our society compels health care workers to ensure a safe healthcare environment for patients with suicidal ideation. These efforts include the elimination or, at least, the mitigation of physical setting characteristics that enable suicide attempts.
Are you depressed? How does this problem make you feel? What makes the problem better?
According to DSM-5 (2013) diagnostic criteria, MDD requires five or more of the following symptoms during the same two-week period and represent a change from previous functioning; at least one symptom is either 1) depressed mood or 2) loss of interest or pleasure (American Psychiatric Association [APA], 2013).
According to the patient’s file, he has experienced five or more of the symptoms of MDD during the same two-week period, on more than one occasion, including depressed mood, recurrent suicidal ideation, and suicide attempts, and was diagnosed with major depression for the first time when he was 23.
How often do you take your medication and how long did you take them before stopping? The patient has a history of stopping his medication, self-medication and non-adherent to treatment. This question is necessary because most antidepressants take a while to build up in the system.
Sources of information
From the social history, patient was married and divorced 3 times, currently single, has no children, nonsmoker no drug abuse, rarely drinks, he’s a Physician and successful businessman. We can elicit information from siblings, extended relatives and even colleagues at work. childhood traumatic experiences, including physical, sexual, and emotional abuse, neglect, and separation from caregivers, significantly increase the risk of developing mental and physical illnesses later in life (
McConnell, et. al, (2019). Colleagues at work and close friends can also be asked about his temperament and attitude at work as this could help with diagnosis and treatment modalities. Also, if patient has access to weapon at home, the relatives might have to make sure it is locked in a safe place or removed if he is currently suicidal.
Physical Exam and Diagnostic tests.
Health assessment will ensure a structured approach that includes comprehensive history taking and meticulous physical examination, carrying out these two parts consecutively enables the examiner to assess the presenting complaint, establish an accurate differential diagnosis and provide any necessary interventions Kennedy & O’Connor, (2016). Physical examination of a patient will include looking at the patient’s overall appearance skin color, turgor and general assessment. Skin for self-injury and discoloration, bruise, vital sign, BMI, general appearance, nutritional status. Gait, balance coordination, reflexes, and involuntary movements, mental status for evidence of mental disorder and thought process.
Electroconvulsive therapy (ECT) according to Birrer & Vemuri, (2004) is a first-line option in patients with depression and psychotic features who have not responded to antipsychotic and antidepressant medications, and patients with severe nonpsychotic depression who have not responded to adequate trials of two antidepressant.
I will in addition to the above check the Erythrocyte Sedimentation Rate (ESR). A change in ESR between two visits was also significantly correlated with a change in PGA, renal, fatigue and joint VAS, (Stojan, Fang, Magder & Petri, 2013). This test is vital to our study because most drugs are eliminated through this media.
1. I think Major Depressive Disorder (MDD) is the main diagnoses for my client. Major depressive disorder (MDD) is defined as “feelings of sadness and/or a loss of interest in activities once enjoyed. It can lead to a variety of emotional and physical problems and can decrease a person’s ability to function at work and at home” and it is one of the most common reasons patients present for medical care worldwide (McConnell, Carter & Patterson, 2019). According to the patient’s file, he has experienced five or more of the symptoms of MDD during the same two-week period, on more than one occasion, including depressed mood, recurrent suicidal ideation, and suicide attempts, and was diagnosed with major depression for the first time when he was 23 (APA, 2013; Stahl, 2011).
1. Borderline personality disorder. The Statistics Manual of Mental Disorders (5th ed.; DSM-5), include fear of abandonment, destructive impulsivity, self-harm, suicidality (evidenced by threats or gestures of self-mutilation), and intense, uncontrollable, or inappropriate anger (American Psychiatric Association, 2013). Per report, patient has depressive symptoms characterized as unhappiness and transient depressed moods of a few days’ duration and with more anxiety than depression, improving without treatment – Actively suicidal and overdosed on his medications.
2. Bipolar II with mixed features; the Diagnostic and Statistical Manual of Mental Disorders (DSM) version 5 stipulates that a diagnosis of BP II disorder cannot be assigned unless the patient has experienced hypomania for four days or longer, however, many studies according to McCraw, S., & Parker, (2016), have shown that the demographic and clinical features of BP II patients with short (i.e. one to three days) hypomanic states are similar to those of patients who meet criteria for DSM-defined hypomania across a range of clinical variables such as age at disorder onset, symptom severity, number of previous episodes of hypomania, number of past hospitalizations, presence of mixed states and family history. Thus, it appears likely that patients with short hypomanic episodes may benefit from the same treatments which are effective for a DSM-defined BP II condition. Patient from report did endorse that since age 23, he has had many episodes lasting a week or more of irritability, inflated self-esteem, increased goal-directed work activity, decreased need for sleep, over talkativeness, racing thoughts, psychomotor agitation and risky behavior; could also experience euphoria or expansiveness to a significant degree but only for 2 or 3 days at most and usually shorter.
Review of medication
With this patient experiencing MDD mixed with some hypomanic episodes, my first choice of medication will be Abilify (aripiprazole) 15 mg orally daily. This medication exerts its effect by working on the CYP2D6 and 3A4 enzymes which some variations of metabolism in different races (Dean, 2016). I will start low and titrate up to minimize the incidence of side effects and improve patient’s compliance, incase my patient is a poor metabolizer. According to McIntyre, Ng-Mak, Chuang, Halperm, Patel, Rajagopalan, and Loebel (2017), antidepressants should be chosen with caution because they can induce mania and distort mood. The patient is already experiencing mixed features of hypomania; thus, antidepressant will not be initiated. Abilify, an atypical antipsychotic according to Stahl (2014), is first line for MDD with mixed features. Abilify has a monthly injectable, which will might help with compliance. Symptoms may improve in a week, but it takes at least 4-6weeks to determine drug efficacy (Stahl, 2014b). The patient has been non-compliant with his medications, so the injectable might prove worthwhile.
2. My second drug of choice will be Lurasidone 20 mg (Latuda) oral daily; This medication according to Stahl, (2013) treat Bipolar depression, acute mania/mixed mania, other psychotic disorders, bipolar maintenance and treatment-resistant depression. This medication in addition to Olanzapine-fluoxetine combination (OFC), quetiapine (either the standard or the extended release preparation), and lurasidone are the only FDA drugs granted (extended) approval for the (acute) treatment of bipolar depression in adults (Fornaro, De Berardis, Perna, Solmi, Veronese, Orsolini, Bartolomeis, 2017).
The medication exerts its effectiveness by blocking dopamine 2 receptors, reducing positive symptoms of psychosis and stabilizing affective symptoms and blocking serotonin 2A receptors, causing enhancement of dopamine release in certain brain regions and thus reducing motor side effects and possibly improving cognition and affective symptoms.
Taking care of patients in the medical field often pose a great challenge. This patient is a typical case of the above. He is a prescriber and is self-medicating and is initiating and ceasing therapy and altering the doses of prescribed medications against the advice from his psychiatric providers. Therefore, nurse practitioners should be able to perform a thorough assessment and conduct the necessary physical examinations on patients.
This patient has a history of noncompliance with medications and self-medicates, he should be monitored weekly and relevant diagnostic tests conducted to ensure compliance with treatment modalities.
Response # 2
This discussion is about a case study of a 60-year-old male, whom has struggled with depression for the past 40 years.
The male has done well with his current treatment until recently. His family noticed that he was less active, not very joyful, feeling hopeless, and worthless. Client has a family history pf mental illness. His medical history includes osteoporosis, hypertension, hypercholesterolemia, enlarged prostate, and arthritis. He has been on different treatments in the past. Diagnostic testing was performed.
Three questions I would choose the ask my patient would be Are there any significant life changes that occurred in the last five years to trigger an exacerbation in depression? This would allow us to review if anything specifically exacerbated his symptoms. Do you have suicidal thoughts or any past suicidal attempts? We want to make sure that the patient is not at risk of committing suicide (Fried & Nesse, 2015). Lastly, I would ask the patient if they feel safe at home? This is important because our patient’s safety is very important (Laff, 2016).
When assessing a patient, it is nice to allow the family to be involved if they are supportive and want to help the patient’s health improve. Some questions that the provider may want to ask the family are: How are the family dynamics, Does the patient’s symptoms get worse in certain environments, and What does the family member suffering from depression in their home environment? These are important questions to help develop a picture of what is going on with the patient (Laff, 2016).
Physical Exam and Diagnostic Testing
When assessing the patient for Major depressive disorder you want to examine the patients’ depressive symptoms. In the case study the patient had lost interest in activities, feeling sad, no joy, worthless, and hopeless. The patient was having trouble concentrating. Scales are major when screening for depression. The scale cannot diagnose a patient but can help confirm a diagnosis and tell us the severity of the depression. Some appropriate screens include patient health questionnaire (PHQ-2), patient health questionnaire 9 (PHQ9), ZUNG scale, and Beck depression inventory (BDI). Diagnostic testing is useful in ruling out any other diseases/conditions that may be causing the depression. We run a blood test such as complete blood count, comprehensive metabolic panel, and thyroid panel. We want to make sure the patient does not have organic disease, infection or a thyroid disorder that may be causing the depressive symptoms (Ng, How, & Ng, 2016).
The three differential diagnosis I have chosen are adjustment disorder, persistent depression disorder (dysthymia), and bipolar disorder. Adjustment disorder is an emotional or behavioral reaction over several months of stressful events or changes in a person’s life. Dysthymia is a chronic mood disorder with a duration of at least two years, the person does not experience pleasure, displays other depressive symptoms that can affect the person’s overall quality of life. Bipolar disorder is a mood disorder that has relapsing and remitting spells of mania and depression, the individual experiences depression more than mania (Lee & Swartz, 2017).
In this case study, the patient was started on Abilify and venlafaxine. Another good medication choice for initial treatment would be SSRIs. Abilify has side effects of weight gain, increased lipid levels, EPS, nausea, vomiting, and dry mouth. Venlafaxine can increase blood pressure. SSRIs such as Prozac Zoloft, or Celexa. This SSRI has fewer side effects and is safe. The SSRIs turn off the production of new serotonin, sending the message to the brain to continue making serotonin (Edwards, 2018). SSRI’s are do not have dietary restrictions like MAOIs, or cause heart disturbances and orthostatic hypotension SSRI (Bressert, 2017).
Follow-ups are used to evaluate the progression of the patient’s symptoms. Practitioners evaluate medication side effects, the effectiveness of the medication, and the patient’s symptoms. It can take 4-8 weeks to know the effectiveness of a medication. In the case study, they followed up with the patient every four weeks. This case study taught the lesson of thinking outside of the box and using diagnostic tools to help improve the patient’s symptoms. The therapeutic dosages for venlafaxine, the initial dosage is 37.5 mg, the maintenance dose is 75 mg -100 mg, moderate depression is 225 mg, and severe depression is 375 mg (Drugs.com, 2019). This practitioner used blood levels to find the patient’s therapeutic dosage. By doing this the patient developed remission.
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