Homework 3

Page 1 of 4

Case Scenario 1: Shubha Referred for Symptoms of Depression

Shubha is a 26-year-old woman who has been referred to you by her primary care physician. Shuhba’s husband and members of his extended family are patients at your clinic, but this is the first time you have met her. Shubha emigrated from Bangladesh to the US three years ago with her husband and family, and gave birth to a baby girl one month ago. She has had an arranged marriage and the family have struggled with financial pressures since the move. Her husband is very close to his mother, who advises him on all issues related to the baby.

Shubha can speak limited English. She is unhappy about the appointment with you because she feels it will bring shame to the family. She is accompanied by her husband to the appointment, who acts as an interpreter. Her husband says that she seems unhappy and does not want to do anything. She is reluctant to get out of bed or to look after the baby, and complains of pain in her stomach constantly. He discloses that his mother thinks she is lazy because she is unwilling to do household chores.

Her husband says Shubha did no disclose any past medical history to him, so her past psychiatric history is unknown.

On further probing, you are told that Shubha feels that it will be better for her baby if she was dead. She believes that she is worthless and that her husband’s family do not like her. She reveals that this has also started to affect how she feels about spending time with her baby. She tells you that she is sometimes reluctant to feed the baby, she often misses meals, and has found she does not have the energy to look after herself as well as she used to.

Page 2 of 4

Case Scenario 2: James Referred for Problems with Resistance to Hemodialysis

James is a longstanding patient at your primary care clinic. He is 47 year old African American man and was diagnosed two years ago with stage 5 chronic kidney disease due to accelerated hypertension. He also has asthma and is Hepatitis C positive.

James had been an IT consultant but is not currently working because of his medical problems. He has been separated from his wife since 2003. Because of his renal impairment, he is seen in an advanced chronic kidney disease clinic and he has recently been told by a renal specialist that he needs to start hemodialysis as his renal replacement therapy. However, James is resistant to this new stage of treatment.

On direct questioning, James reports feeling very tired to the point of weariness, says that his memory has been affected recently, that he has a lack of interest in his hobbies, and is finding it difficult to be able to enjoy everyday activities such as watching the television or sharing a meal with his family.

James speaks in short sentences and rarely makes eye contact. Most of his replies are ‘yes’ and ‘no’ and he frequently needs direct questions to prompt answers. James shows signs of poor hygiene and self care.

James discloses that he has been feeling low for quite a long period of times. He explains that he had begun to feel down from around the age of 15, and that he had experienced frequent periods of physical and emotional abuse as a teenager. He states that at times he just didn’t feel good enough and often struggled with trying to fit in with the social groups at his school and this left him often feeling quite isolated.

Page 3 of 4

Case Scenario 3: Fred Referred for Problems with Sleeping

Fred, aged 45, is a locksmith. He has longstanding and persistent worries that he has not done his job properly and that someone’s house might get broken into as a result. He worries he might have given customers the wrong change whenever they have paid him in cash. Fred informs you that he worries about many things in his life, and his most common thought is ‘what if’? He often imagines the worst happening and states that when he worries, he often feels sick, has headaches, feels butterflies in his stomach and is aware of his heart pounding. Fred often gets hot and sweaty and says his anxiety makes it difficult to concentrate and do his job or play with his children. He is very distressed by his constant worrying and feelings of anxiety, and regards it as a sign of weakness. He said that he was wanting help with his sleep problems, but that he is really under considerable stress.

Fred has no medical history of note. He looks distressed and is clearly sweating despite the fact that it is not warm in the room. When asked how things are for him at work and at home, he mentions that he has found work a bit difficult recently. He fears his levels of stress and anxiety will cause him to make a mistake at work and someone’s house will get broken into. He says that he worries his stress levels will make him go mad. He says that he sometimes thinks that his family and the world would be better off without him.

He says, “I haven’t had any mental health problems in the past. I have never had any help – I am too ashamed. It’s not very ‘manly’ to worry is it?

Page 4 of 4

Case Presentation 4: Andre Referred for Problems with Adherence to Diabetes Medications

Andre is a 52 year old self-employed builder who has diabetes. He tells you he is a gay man and has been “out” since he was a teenager. He complains that he has been increasingly tired for the last 5 months. His sleep is poor and he says he can’t be bothered to shave in the morning. He says that his primary care doctor was unhappy with his diabetic control and that his husband has now insisted that he see a psychotherapist.

Andre smokes around 12 cigarettes a day, mostly at work, since his husband won’t let him smoke in their house. He has hypertension and has been receiving an antihypertensive drug for the last 5 years. He takes an oral statin to lower his cholesterol and an oral medication for his diabetes. Andre says he loves wine and drinks some wine every evening with his husband. He says he has lost his appetite, and is finding his eating is ‘all over the place.’ He is usually in bed by 10 PM and has no problems getting to sleep but has begun to recently experience sleep disturbance as he wakes up once or twice at night to go to the toilet. He says when he wakes in the morning he ‘feels tired and finds it hard to get out of bed.’

Andre looks overweight and has a body mass index of 32. When last seen by his primary care doctor his HbA1c had increased from 8% to 9.2% (when the target is 7.5%). His cholesterol level was also higher than his previous visit. His current blood pressure is 145/85 mm/Hg. He admits he has been a bit forgetful with his medications, and has skipped some doses. He appears low in mood, avoids eye contact, and says he doesn’t find life as fun as it used to be. He blames himself for not being able to ‘pull himself together.’ When asked he says his concentration is OK, and he is able to correctly remember his date of birth but struggles to remember what month we are in now.