wk9 Respond to Chris

Respond to Chris’s presentation Read the entire presentation. Provide a response to 1 of the 3 discussion questions that your colleagues provided in their video presentations. You may also provide additional information, alternative points of view, research to support treatment, or patient education strategies you might use with the relevant patient. Discussion questions 1. How does DSM 5 categorize MDD? Is it different for recurrent MDD? 2. Why is it important to perform the lab work and diagnostics mentioned in this presentation for this patient? 3. Why is Nortriptyline not considered a first line treatment option for MDD? Week (9): (Soap Note) Student name: Chris NRNP 6675: PMHNP Care Across the Lifespan II Dr. M. Reyes July 2021

Week (9): (Soap Note)

Objectives

1. After reviewing this presentation, you will be able describe the symptoms

associated with MDD.

2. After reviewing this presentation, you will understand why CBT and a tricyclic

antidepressant can be an effective treatment plan for a patient with MDD.

3. After reviewing this presentation, you will be able to identify the differential diagnoses and the actual diagnosis.

4. After reviewing this presentation, you will be able to discuss treatment options in

managing a patient with MDD.

Subjective Data:

CC (chief complaint): Patient states, “My nephew passed away and I have been feeling

very down”.

HPI: Initial appointment with a 72-year-old Caucasian female patient who is here

today with a history of MDD. Patient is seen today via telehealth. She appears well-

groomed, appropriate for her age, and is alert and orientated to person, place, and time.

She has been diagnosed with MDD since her 40’s. Patient states that over the past

several months she has felt an increase in sadness, anhedonia, insomnia, loss of

energy, and decrease in appetite. She has had feelings of sadness and anhedonia

nearly every day. Her nephew passed away a few months ago and it has been

exceedingly difficult for her. The stress of the pandemic and her nephew’s death has

caused a relapse of her depressive symptoms. Her memory appears intact. Patient has

been stable for last 12 months on Nortriptyline 25 mg po daily until about 2 months ago.

Patient states she has a history of Diabetes, HTN, and HLD. Patient did not endorse SI

or HI.

Substance Current Use: Alcohol only occasionally

Medical History: Diabetes on Metformin

Family History: mom with anxiety

Past Hospitalizations: Never been hospitalized for psychiatry

• Current Medications: Metformin 500mg po tid, Lisinopril 40mg po daily,

Metoprolol 200mg po daily, atorvastatin 20mg po daily, Nortriptyline 25mg po daily

• Past medications: Cymbalta 30mg po daily (was not effective), Sertraline 50mg

po daily (became ineffective), Bupropion unsure of dose (became ineffective)

• Allergies: NKA

• Reproductive Hx: G2P2

ROS:

• GENERAL: She is alert and oriented x 4. She is in good general appearance, no

fever, appears to be of normal height and weight for stated age. She denies

weakness but does feel more fatigued.

• HEENT: no discharge or complaints of distress, moist mucous membranes,

patient wears glasses. Sclera appears white. Patient denies any hearing loss, cough

and or congestion.

• SKIN: appears warm and dry and patient denies rash or itching

• CARDIOVASCULAR: no evidence of chest pain or palpitations, hx HTN and HLD

• RESPIRATORY: no sob or respiratory distress noted

• GASTROINTESTINAL: No evidence of nausea/ vomiting or abdominal pain

• GENITOURINARY: no issues noted or expressed

• NEUROLOGICAL: no issues noted

• MUSCULOSKELETAL: Full ROM to all extremities, denies pain

• HEMATOLOGIC: none noted, denies bleeding problems and no bruising noted

• LYMPHATICS: no problems noted, no enlarged nodes or history

• ENDOCRINOLOGIC: HX of diabetes

Objective Data:

Diagnostic results: Full psychiatric interview and assessment. Lab work to be ordered

includes HgbA1c, LFTs, CBC, CMP, Lipid panel, Thyroid panel. Patient has not had lab

work done in over a year, so it is important to ensure no other medical reason for return

of symptoms. PQ9 was completed as well as mood questionnaire and Beck depression

screening. Patient scored a 24 on the PQ9 and scores over 20 suggest severe

depression. She scored a 50 on the depression inventory which again suggest severe

depression. Patient denied any symptoms of mania/ hypomania, and none was noted at time of interview.

Assessment

Mental Status Examination:

Patient is Alert and oriented x 4. Patient can answer other questions appropriately.

Patient appears clean and is dressed appropriately. She has been cooperative

throughout the interview. Motor activity is appropriate and intact, gait is stable. Patients’

speech is of normal tone and normal speed. Her mood is depressed, and her affect is

broad with feelings of increased depression over the last several months. Her thoughts

are appropriate and logical with feelings of depression over recent pandemic and loss of

family member. Thoughts are organized and goal directed. No evidence of disorganized

thinking. Patient denies hallucinations and delusions. Patient denies suicidal ideations

as well as homicidal ideation. Her attention and concentration are appropriate for her

age and situation. She appears calm during interview. Her memory and recall are intact,

and she can adequately recall dates and times of events. Judgement and insight are

rational and logical.

Diagnostic Impression

Differential Diagnosis:

1. Generalized anxiety disorder F41.1- For a diagnosis of GAD the patient must present with excessive anxiety and worry occurring on most days for at least 6

months. They also must have 3 or more of the following symptoms: restlessness,

fatigue, trouble concentrating, muscle tension, sleep disturbance and it must also

significantly affect their life (American Psychiatric Association, 2013). Although patient

does have some of the symptoms mentioned in the criteria for GAD it does not cover all

her the symptoms she is currently having.

2. Adjustment Disorder with depressed mood F43.21-

Adjustment disorder describes a maladaptive emotional and/or behavioral

response to an identifiable psychosocial stressor, must occur within three months

of the stressor and must cause significant impairment in functioning (O'Donnell et al.,

2019). Patient does have the depressed mood however the patient does not meet

symptoms for adjustment disorder as she has been diagnosed with MDD for many

years and is just showing a return of symptoms.

3. Bipolar disorder F31.11- For a diagnosis of BPDO patient must have a persistent

elevated mood and increased energy pr activity, lasting at least 4 consecutive days

and present on most days. Patient must have three or more of the following

symptoms: inflated self-esteem, decreased need for sleep, more talkative, flight of

ideas, distractibility, and or excessive involvement in activities (American

Psychiatric Association, 2013). Along with the hypomanic symptoms’ patient must also meet the criteria for a major depressive episode which are consistent with MDD. Patient did not endorse any episodes of mania or hypomania and therefore does not meet criteria for BPDO.

Actual Diagnosis

1. Major Depressive Disorder severe recurrent episode (MDD) F33.2- For a

diagnosis of MDD a patient must have persistent symptoms for at least 2 weeks that

include at least 5 of the following symptoms: depressed mood, loss of interest or

pleasure, change in appetite, sleep disturbance, psychomotor changes, increase

fatigue or decrease in energy, feelings of guilt, difficulty with concentration, and or

thought of suicide or self-harm (American Psychiatric Association, 2013).

Patient meets criteria for MDD due to her endorsement of the following symptoms: feelings of sadness, anhedonia, difficulty sleeping, loss of appetite, and loss of energy. This is a recurrent episode for the patient and after completing interview, PQ9 and Beck depression screener this episode may be classified as severe.

Reflections:

I agree with my preceptor that patient meets criteria for recurrent severe

Major depressive disorder. Patient stated that the symptoms have become worse over

the last 5 months and include feelings of sadness, anhedonia, difficulty sleeping, loss of

appetite, and loss of energy. She has feelings of loss of interest almost every day and

finds it exceedingly difficult to get out of bed in the morning. I also agree that an

increase in her Nortriptyline is appropriate since the medication has been working for

her depression prior to this increase in symptoms. I also think that the addition of

psychotherapy would be beneficial for patient as she has not had psychotherapy for the

last year. We will set patient up for CBT session with therapist here at clinic. “Cognitive

behavioral therapy (CBT) is one of the most evidence-based psychological interventions

for the treatment of several psychiatric disorders such as depression, anxiety disorders,

somatoform disorder, and substance use disorder” (Gautam et al., 2020). It is also

important to see the patient back in clinic within the next 3-4 weeks to evaluate for

effectiveness and any unwanted side effects.

Case Formulation and Treatment Plan:

The following lab work to be ordered: HgbA1c, LFTs, CBC, CMP, Lipid panel, Thyroid

panel, and EKG (patient is over 50) to rule out any other possible medical

conditions. My initial request would be for patient to immediately begin psychotherapy

and therefore, it will be set up with a therapist for CBT sessions here in the clinic.

Patient has had success with Nortriptyline for her depressive symptoms so at this time

we will increase her Nortriptyline from 25mg po daily to 50mg po daily. Tricyclic

antidepressants are not usually utilized as a first line treatment for depression due to its

significant side effect profile (Moraczewski, & Aedma, 2020). However, for this patient

has been effective and has not caused any significant side effects for her. Therefore,

treatment will include Nortriptyline 50mg po daily, CBT weekly sessions and return to

see PMHNP in 3-4 weeks. CBT can be an effective addition to the patient’s medication

and can also help prevent relapse in the future (Driessen, & Hollon,2010).

Client was provided with emergency numbers: Emergency Services 911, the Client’s

Crisis Line 1-800- 273- 8255. Client instructed to go to nearest ER or call 911 if they

become actively suicidal and/or homicidal.

• Reviewed risks, benefits, major/common side effects specifically constipation,

dizziness, blurred vision, urinary retention, confusion, and or tachycardia. All reviewed

with patient who stated understanding and agreement with plan. The client told to

abstain from ETOH and other substances while starting on increase of medication.

• Individual Therapy weekly, PMHNP follow up and medication management in 3-4

weeks.

Discussion questions

1. How does DSM 5 categorize MDD? Is it different for recurrent MDD?

2. Why is it important to perform the lab work and diagnostics mentioned in this

presentation for this patient?

3. Why is Nortriptyline not considered a first line treatment option for MDD?

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental

disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596

Driessen, E., & Hollon, S. D. (2010). Cognitive behavioral therapy for mood disorders:

efficacy, moderators and mediators. The Psychiatric clinics of North America,

33(3), 537–555. https://doi.org/10.1016/j.psc.2010.04.005

Gautam, M., Tripathi, A., Deshmukh, D., & Gaur, M. (2020). Cognitive Behavioral

Therapy for Depression. Indian journal of psychiatry, 62(Suppl 2), S223–S229.

https://doi.org/10.4103/psychiatry.IndianJPsychiatry_772_19

Moraczewski, J., & Aedma, K. K. (2020). Tricyclic Antidepressants. In StatPearls.

StatPearls Publishing.

O’Donnell, M. L., Agathos, J. A., Metcalf, O., Gibson, K., & Lau, W. (2019).

Adjustment disorder: Current developments and future directions. International Journal of Environmental Research and Public Health, 16(14), 2537. https://doi.org/10.3390/ijerph16142537