Grand Rounds Discussion: Complex Case Study Presentation

Week (9): (Ground Rounds Discussion: Complex Case Study Presentation)

Judith Uwazuruonye

College of Nursing-PMHNP, Walden University

NRNP 6675: PMHNP Care Across the Lifespan II

DR Ishkova

July 27, 2022

Presentation Objectives

i. To perform a comprehensive psychiatric patient evaluation on the patient.

ii. To develop a differential diagnosis based on the subjective and objective data obtained.

iii. To determine the most reasonable diagnosis based on the patient’s symptoms.

iv. To develop a patient-centered treatment plan for the patient.

Subjective:

CC (chief complaint): “Anxiety on going out.”

HPI: L.L. is a 65 years old African American patient seeking help in managing anxiety. The patient admits to feeling anxiety when going to the stores and driving from her comfort zone. She struggles with overwhelming anxiety and avoidance of the anxiety. The onset of her anxiety was gradual following an incident in the early 2000s when she experienced an episode of encopresis before she could make it to the bathroom. Since the event, she has been avoiding going to stores and gradually grew anxious when driving due to the fear of getting lost and losing control. Since her retirement, the fear has increased significantly, and this has kept her away from seeing her family, going to physician appointments alone, and engaging in recreational activities. She has few friends, is widowed, and is not in a relationship. She lives with her children in a rented apartment. Her medical history is positive for irritable bowel syndrome and glaucoma. She denies a history of military service, legal issues, or drug or substance abuse. Her medication list includes Buspar 2.5mg P.O. in the evening. She was previously on Zoloft 25mg daily, but this was discontinued due to the feeling of drowsiness. She feels depressed due to the fear of leaving her house. She is allergic to Biaxin. L.L. reports not being compliant with her medications and requiring the withdrawal of the current medications.

Substance Current Use: Denies

Medical History:

· Current Medications: None

· Allergies: Biaxil. Unknown reaction

· Reproductive Hx: Post-menopausal. Has 3 children. Not sexually active. Widowed.

· Surgery: No past surgery

Family history

Mother- generalized anxiety disorder

Father- Alcohol use disorder

Children- No remarkable health issues

Social history

The patient lives in a rented apartment with her children. She is widowed and is not currently in a relationship. She is retired. She denies a history of drug or substance use, legal issues, or military history. The patient denies a history of abuse or trauma when growing up and in her adulthood, except for the loss of her husband. She maintains few friends and reports feeling anxious when going out. She is afraid of driving from her comfort zone due to the fear of losing control or getting lost.

ROS:

· GENERAL: The patient reports increased anxiety and non-compliance to medications. She denies any unexplained changes in weight or appetite.

· HEENT: Head: No history of trauma, headache, or hair pulling. Eyes: No vision challenges, use of vision aids, or pain. Ears: No history of ear infections, hearing problems, or pain. Nose: No blockage or wheezing. Throat: No swollen tonsils, swallowing problems, or pain.

· SKIN: No cuts, rashes, bruises, or wounds.

· CARDIOVASCULAR: No pain, congestion, or pressure in the chest. No changes in heart rate. No palpitations.

· RESPIRATORY: No breathing difficulties, shortness of breath, or pain, congestion, or pressure in the chest.

· GASTROINTESTINAL: Has a history of irritable bowel syndrome. No changes in weight or appetite.

· GENITOURINARY: No incontinence, enuresis, or increased frequency. Denies pain, burning sensation, or irritation during urination.

· NEUROLOGICAL: No history of falls, blackouts, syncope, or tremors.

· MUSCULOSKELETAL: No history of broken bones. Denies pain or weakness on any muscle, joint, or bone.

· HEMATOLOGIC: No easy bruising or bleeding. No history of anemia.

· LYMPHATICS: No unusual sweating or chills. No swollen lymph nodes.

· ENDOCRINOLOGIC: No hunger, thirst, hunger, urination, or bowel movement, or urination.

Objective:

· GENERAL: The patient is alert and oriented to all four spheres during the interview. She is a good historian and the primary source of health information. Her concentration and attention are adequate and she does not demonstrate pressure, agitation, or unusual mannerisms.

· HEENT: Head: Normocephalic and atraumatic head. Norma hair pattern and color for a 65 years old African American female. Eyes: PERRLA. No jaundice. Has glaucoma. Ears: Gray tympanic membranes. Nose: No running nose. Throat: No hoarse voice, odor, or inflammation.

· SKIN: No bruises, cuts, dyspigmentation, or burns.

· VITAL SIGNS: H, 5’5”. W, 139lbs. BMI 23.1. T 990F. RR 18. BP 124/80mmHg left arm cuff while seated.

· CARDIOVASCULAR: No gallops or murmurs.

· RESPIRATORY: All lung fields are clear to auscultation.

· GASTROINTESTINAL: Hyperactive bowel sounds.

· GENITOURINARY: Not assessed.

· NEUROLOGICAL: No tremors or coordination problems noted. No syncope or dizziness. No ambulation difficulties.

· MUSCULOSKELETAL: No bone fractures, or ambulation difficulties.

· HEMATOLOGIC: No bleeding problems. No bruises or cuts, jaundice, or scarring.

· LYMPHATICS: No hair loss, baldness, or swollen lymph nodes.

· ENDOCRINOLOGIC: No chills or sweating.

Diagnostic results:

CBC- Normal

Urine drug tests- Alcohol, marijuana, cocaine, heroin- Within normal limits

Assessment:

Mental Status Examination: L.L. is a 65 years old African American woman appearing to be of the stated age. The patient is fully awake, alert, and oriented x4. She is appropriately dressed and well groomed. She is cooperative and maintains good eye contact with the practitioner. Speech is normal, mood is euthymic, and affect is congruent. Thought processes are goal-directed, organized, and logical, thought content is future-oriented and without suicidal, homicidal, or self-harm intentions. Her insight, judgement, long-term, and short-term memory are intact. Attention and concentration are adequate for the session, language (naming and repeating phrases) is intact, and her fund of knowledge is average.

Diagnostic Impression:

Agoraphobia

The DSM-5 defines agoraphobia as anxiety of being in situations or places where one might be embarrassed and not be able to escape (Roest et al., 2019). It is the fear of being in places where help may not be readily available in case of an undesired event. The patient admits fearing going out and driving from her comfort zone. Her fear is related to an encopresis incidence experienced in the early 2000s. She states that she observes precautions such as asking where the bathrooms are whenever she is outside. According to the DSM-5 criteria, agoraphobia is characterized by marked fear of being in open spaces, standing in line, outside home alone, using public transportation, or being in enclosed spaces (Roest et al., 2019). In addition, she actively avoids traveling to these places. These situations provoke anxiety in the patient, and this is often out of proportion to the actual danger posed by the situation. The anxiety has been persistent and has increased gradually over the last 20 years. The patient meets the criteria for two of these symptoms, making it a positive diagnosis.

Social Anxiety Disorder

According to the DSM-5 criteria, social anxiety disorder (SAD) is characterized by marked fear of being in social situations (Park & Kim, 2020). Often, patients experience significant fear when expecting to be in social situations such as family gatherings, meetings, or in crowded places. L.L. admits having significant fear of being in public places and leaving her house. Specific symptoms of SAD include feeling distressed due to social interactions, fear of specific social settings, fear of social rejection due to anxiety, avoidance of social interactions, and the fear is not related to underlying health issue, drug abuse, or substance use. The patient’s fear is attributed to bowel problems and the associated encopresis incident experiences about 20 years ago. She fears being lost and losing control.

Major Depressive Disorder 

Patients with major depressive disorder (MDD) exhibit significant distress and declined interest in things they used to enjoy (Tolentino & Schmidt, 2018). The patient reports feeling distressed due to the inability to leave her home. She is also unable to enjoy going out and traveling as she used to when she was younger. Other symptoms of MDD described in the DSM-5 include diminished concentration and attention, weight changes, appetite changes, suicidal ideations, anhedonia, hopelessness and worthless, guilt, and irritability. The patient does not demonstrate the (at least) five symptoms as required in the DSM-5 criteria for a positive MDD diagnosis.

Reflections:

If the patient were to be assessed again, it would be essential to evaluate the impact of the identified stressors, including the loss of her husband, on her life. The loss of a loved one often causes significant distress, leading to disorders such as major depression (Magill et al., 2022). Major changes in her life, including menopause and retirement, also increase the risk for psychological health issues. Asking probing questions related to these issues can help identify how they affect her wellness and develop coping strategies to reduce the risk of complications.

The patient reports not be adherent to the treatment plan. It is essential to assess the reasons for non-compliance and collaborate with her to develop measures to optimize compliance. During follow-up, practitioners should consider changes in the patient's symptoms towards achieving recovery and side effects experienced from the medications (Tasca et al., 2019). In addition, the practitioner should collaborate with the patient to develop strategies to promote compliance, including adjusting the treatment plan. 

Case Formulation and Treatment Plan: 

Pharmacotherapy. Her medications were withdrawn from her treatment plan due to non-compliance related to adverse side effects. Her PCP also advised her to withdraw the medications.

Psychotherapy, psychoeducation, and health promotion: 

Cognitive behavioral therapy is recommended for the management of agoraphobia. Patients require 6-8 sessions over a treatment course lasting about 12 weeks (Andrews et al., 2018). The practitioner helps the patient analyze her fear and develop cognitive and behavioral techniques to address the anxiety during CBT. Collaborative, the therapist and the patient identify and implement approaches that may work best for them.

Psychoeducation on treatment adherence is essential for this patient based on her history of non-compliance to treatment. This should include issues such as treatment tolerance and the risk for complications. The practitioner should encourage the patient to consult professional help when she feels ready to take medications.

Health promotion should include patient education on the benefits of regular physical activities and heart-healthy dieting in protecting against chronic health issues (Rivera-Torres et al., 2019). Due to her advanced age, regular physical activity can improve her cardiovascular health and lower the risk for the problems such as heart failure, heart attack, stroke, and diabetes. Exercises can also improve her physical wellness. Healthy dieting can improve weight management and protect against cardiometabolic health issues.

Reflection Questions

1. What strategies can be implemented in this patient to promote treatment compliance?

2. Based on the patient’s symptoms, what is the most relevant DSM-5 diagnosis?

3. Discuss different risk factors to the agoraphia and social anxety disorder.

References

Andrews, G., Bell, C., Boyce, P., Gale, C., Lampe, L., Marwat, O., ... & Wilkins, G. (2018). Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of panic disorder, social anxiety disorder and generalised anxiety disorder. Australian & New Zealand Journal of Psychiatry, 52(12), 1109-1172. https://doi.org/10.1177%2F0004867418799453

Magill, N., Walker, J., Symeonides, S., Gourley, C., Hobbs, H., Rosenstein, D., ... & Sharpe, M. (2022). Depression and anxiety during the year before death from cancer. Journal of Psychosomatic Research, 158, 110922. https://doi.org/10.1016/j.jpsychores.2022.110922

Park, S. C., & Kim, Y. K. (2020). Anxiety Disorders in the DSM-5: Changes, controversies, and future directions. Anxiety Disorders, 187-196. https://doi.org/10.1007/978-981-32-9705-0_12

Rivera-Torres, S., Fahey, T. D., & Rivera, M. A. (2019). Adherence to exercise programs in older adults: informative report. Gerontology and Geriatric Medicine, 5, 2333721418823604. https://doi.org/10.1177%2F2333721418823604

Roest, A. M., de Vries, Y. A., Lim, C. C., Wittchen, H. U., Stein, D. J., Adamowski, T., ... & WHO World Mental Health Survey Collaborators. (2019). A comparison of DSM‐5 and DSM‐IV agoraphobia in the World Mental Health Surveys. Depression and Anxiety, 36(6), 499-510. https://doi.org/10.1002/da.22885

Tasca, G. A., Angus, L., Bonli, R., Drapeau, M., Fitzpatrick, M., Hunsley, J., & Knoll, M. (2019). Outcome and progress monitoring in psychotherapy: Report of a Canadian Psychological Association Task Force. Canadian Psychology, 60(3), 165-177. https://psycnet.apa.org/doi/10.1037/cap0000181

Tolentino, J. C., & Schmidt, S. L. (2018). DSM-5 criteria and depression severity: implications for clinical practice. Frontiers in Psychiatry, 9, 450. https://doi.org/10.3389/fpsyt.2018.00450