I need a reply of about half page of each discussion, with at least 2 references.
Week three discussion
Week 3 Initial post
For this discussion post, I was assigned to case # 2 which is the physician do not heal thyself case. This case study describes a 60-year-old physician with generalized anxiety, history of suicidal attempts, depression from his early 20’s.
Question to ask the Client:
- Are you thinking of harming or killing yourself?
- Do you have any family or friends that you help you at home?
- What do you hope to accomplish with this treatment?
The rationale for the above questions are that you have to first assess his risk for suicide by asking him directly, also ask if he has any social support at home to assist him, and third since he keep changing his prescription, it would be important to know what he hopes to accomplish with all the frequent changes of prescriptions (Informal Health Online, 2017).
I would want to speak with the client’s family members since they live with him and known him best and observe his behaviors, they would best be able to provide important information that will validate the subjective data. Given his troubled or challenging interpersonal relationships, speaking to those who can describe or given examples of his situation would be important.
Diagnostic tests that I will include will be complete blood count, thyroid test, neurology test, BMP, urine test (Lubit, 2017). The rationale for these tests are that they may provide information about possible infection, anemia, they functioning of the thyroid gland and hormone and because the patient has been taking a lot of prescription medication, I would also want to check his urine.
Differential diagnosis would be depression, bipolar disorder and personality disorder (Lubit, 2017). The most likely one is personality disorder as that aligns with symptoms and his inability to maintain relationships or even maintain adequate functional statis in life. The case study notes that this started when the patient was in his adolescent years and this provides additional validation supporting a diagnosis of personality disorder. The case study states a long history of inability to maintain relationships thus giving more likeliness of being personality disorder.
Drug therapy will include starting with Zoloft 50mg daily and increased gradually for a maximum daily dose of not more than 200mg (Mayo Clinic, 2016). After one week, Lexapro 10mg daily could be included. Zoloft is preferred because it is an CNS inhibitor and has fewer side effects. Lexapro is also an inhibitor of reuptake of serotonin and the patient may experience relief of symptoms much earlier than with other drugs (Mayo Clinic, 2016).
During the routine follow-up, it was discovered that he stopped taking some of the medication following uncomfortable side effects. His visits became infrequent and suicidal thoughts returned which made him now seek for help. He is consistent with not being compliant with his drug therapy and because he constantly keep changing his prescriptions, he does not give any of the medications a change to reach a therapeutic level in his system. This can be seen as being manipulative which is a symptom of personality disorder (Lubit, 2017). The fact that he switched to a different psychiatric is also another sign of his manipulation and inability to maintain functional relationships.
Informal Health Online. (2017). Depression: How effective are antidepressants. Retrieved from https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0087089/
Lubit, R. (2017). Borderline personality disorder medication. Medscape. Retrieved from https://emedicine.medscape.com/article/913575-mediation
Mayo Clinic. (2016). Personality Disorders. Retrieved from http://www.mayoclinic.org/diseases-conditions/personality-disorders/symptoms-causes/syc-20354463
Case #3 Initial Post
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Case: The depressed man who thought he was out of options.
- How long have you been struggling with depression for?
- Have you ever had or currently have any thoughts about ending your life?
- How is your support system at home and who is your support system?
Reaching the end of your tolerable rate of depression can be a vital turning point in one’s life. Without the careful consideration about suicide, the client can easily devote the energy to end his existence in this world. Starting off, the advanced practice nurse would want to understand a general history of the client’s conflict with depression to determine the severity and life stressing events. Providing other vital information such as trigger events for this man’s chronic depression. Generally, suicidal ideations can stem from impulsivity or carefully planned methods. Understanding if the client has even begun to think about suicide will determine the risk factor as he already stated the idea of being out of options. Lastly, the support system in life can help balance care and hopefully prevent the client from ending his life. Having a support system is vital to successful treatment of depression in conjunction with antidepressant therapy.
Two import people to speak to in the client’s life would be a significant other or the person whom spends the most time with the client. Asking question regarding lifestyle choices such as how much time does the client spend in isolation? Does the client take his prescribed antidepressant medications? Lastly, asking those individuals if the client feels hopeless or the feeling of having no purpose in life. These questions could lead to provider to develop an understanding of treatment compliance and risk factors through others point of views. Persistence towards treatment is required for antidepressant therapy to work as people often loose hope during the medication’s progression (Stahl, 2013). Not all the time a client could open up about vital information that could ultimately save their life.
A Multitude of depression scales and tools exist within different healthcare facilities and providers. Commonly used, the Beck Depression Inventory Scale, is a twenty-one requestion assessment that can be performed on a client to determine between six levels of depression (Kokoszka et al., 2020). The Beck scale would be appropriate for the client to get a more well-rounded understanding of what the client means by out of options during his depression treatment. Other commonly used scales that could be implemented are the Hamilton Depression Rating Scale or Brief Self-Rating Scale of Depression and Anxiety, allowing the client to fill out the questionnaire without stating his or her answers out loud (Kokoszka et al., 2020). Having a numerical value to assess depression can help the provider monitor progress throughout treatment. Playing a vital role for myself in my own practice, allowing each client the opportunity monthly to complete a depression rating scale. This would provide myself with data throughout the year to monitor the effectiveness of the prescribed antidepressants without the client just stating if they are alright. Generally, the first antidepressant of choice used for treatment does not place the client in remission and a second to third drug must be attempted (Stahl, 2013).
With the belief of being out of options, the diagnostic criteria for the client would be a chronic form of depression. Utilizing the DSM-V the three diagnosis that come to mind would be major depressive disorder, substance induced depressive disorder, and persistent depressive disorder (American Psychiatric Association, 2013). The diagnosis to focus on for the client would be dysthymia, also known as persistent depressive disorder, as it is a chronic form of a depressive mood disorder (Bech, 2016). As the client reaches the end and severe depressive episodes would have plagued the client for a significant portion of time. The client could feel trapped with the inability to stop feeling a constant depression daily.
The first choice for pharmacologic treatment of dysthymia would be to start with a selective serotonin reuptake inhibitor (SSRI) fluoxetine. Fluoxetine has been found to give clients an energizing feeling and reduce overall fatigue after the first dose (Stahl, 2013). Having such rapid action on a client, fluoxetine would be helpful in desperate times of need. Activating effects are due to actions with the 5HT2C receptors which can negatively affect clients with disorders such as panic attacks, severe agitation, insomnia, and anxiety (Stahl, 2013). With none of those disordered mentioned in the case study, the client would be a great candidate for a trail on fluoxetine.
Another pharmacologic agent to utilize towards the client would be bupropion XL 150mg once daily. Bupropion is classified as a nor epinephrine-dopamine re uptake inhibitor (NDRIs) and overall increases the dopamine available in the prefrontal cortex (Stahl, 2013). The increase of dopamine is a result of the NDRIs blocking both nor epinephrine and dopamine focusing on the symptoms of loss of happiness, interest, energy, and joy (Stahl, 2013). With the client diagnosis with dysthymia, there is a significant chance that they have been prescribed past antidepressants. Bupropion has been shown to show positive results when clients have not responded well to SSRIs in the past (Stahl, 2013). Allowing bupropion to be the follow up care for the client if did not react well to fluoxetine.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders
(5th ed.). Washington, DC: Author.
Bech, P., Kessing, L. V., & Bukh, J. D. (2016). The validity of dysthymia to predict clinical
depressive symptoms as measured by the Hamilton Depression Scale at the 5-year follow-up of patients with first episode depression. Nordic Journal of Psychiatry, 70(8), 563–566. https://doi-org.ezp.waldenulibrary.org/10.1080/08039488.2016.1180712
Kokoszka, A., Cichoń, E., Obrębski, M., Kiejna, A., & Rajba, B. (2020). Cut-off points for
Polish-language versions of depression screening tools among patients with Type 2 diabetes. Primary Care Diabetes. https://doi-org.ezp.waldenulibrary.org/10.1016/j.pcd.2020.05.015
Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical
applications (4th ed.). New York, NY: Cambridge University Press.
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