responses

WK9AssgnValdez, E.

Eduardo J. Valdez

College of Nursing-PMHNP, Walden University

PRAC 6675: PMHNP Care Across the Lifespan I

Dr. Lisa Marie Persad

July 22, 2026

Subjective:

CC (chief complaint): “I have struggled with anxiety since childhood. My depression this past month is new, and I’d like help managing it.”

HPI: 66-year-old Caucasian female presenting for initial intake after referral by her LICSW. Patient was interested in Eye Movement Desensitization and Reprosessing therapy (EMDR) but never completed it; she is now EMDR certified herself. She reports lifelong anxiety, new-onset depression, and significant grief due to multiple family losses. She is also looking for a medication adjustetment, and try Transmagnetic Stimulation Therapy at the clinic. History includes a brain surgery in 2012 for acoustic neuroma (now deaf in right ear), and recent increased crying, fatigue, and hopelessness. Denies SI/HI.

Past Psychiatric History: R. B . reports grief but does not really think she has had MDD. reports her mother is a big part of why she presents today. reports her mother always wanted her to be close with her sister - reports mom is age 92 and her father left at age 2 and her mother went out west and at age 12 her mother lived with friends and family etc. abandonment issues.  reports she and her sisters relationship and minimal family and struggling with current

Psychotherapy or Previous Psychiatric diagnosis: R.B. underwent EMDR therapy with the referring therapist, and found it interesting and helpful, leading her to become EMDR certified herself.

Substance Current Use: Denies alcohol, tobacco, or illicit drug use.

Medical History:

· Cataracts

· Heart murmur

· Arthritis

· History of kidney stones, s/p removal November

· Brain surgery (2012, acoustic neuroma, resulting in right ear deafness)

· Medication trials and current medications:

· Went on Zoloft after the abortion at age 31-Switched Lexapro 10 mg 20 years ago.

Currently on:

· Brexpiprazole 0.5 mg tablet

· Auvelity 45 mg-105 mg tablet, exented release

· Estradiol cream 2x/week

· Restasis eye drosp 2 x/day

· Ipratrapium nasal spray

· Lorazepam as needed for sleep

· Allergies:

· Sulfur

· Penicillin

· Reproductive Hx:

· History of abortion at age 31

· Two miscarriages

· Daughter had Marfan syndrome, died at age 4

· Son, age 35, alive and well

· Family History

· Dad (deceased) Diseases: hypertension cancer. Dad died at age 58 of lymphoma

· mom (alive) Diseases: typical old age

· sister (alive) Diseases: multiple myeloma, likely borderline, married a wealthy jewish male age 19 and then divorced years later with two adoptive kids, married again and then had a child with spinabifida

· ROS:

· General: Reports fatigue and increased crying spells; denies fever, weight loss, or night sweats.

· Head: No headaches or dizziness reported.

· Eyes: History of cataracts; no vision changes, pain, or diplopia.

· Ears: Deaf in right ear (s/p acoustic neuroma surgery); no tinnitus, vertigo, or ear pain.

· Nose: Uses ipratropium bromide nasal spray as needed; no nasal congestion, epistaxis, or sinus pain.

· Throat/Mouth: No sore throat, mouth ulcers, or dental pain.

· Neck: No neck pain, stiffness, or lymphadenopathy.

· Cardiovascular: History of heart murmur; denies chest pain, palpitations, syncope, or edema.

· Respiratory: No cough, dyspnea, wheezing, or hemoptysis.

· Gastrointestinal: History of kidney stones (s/p removal); denies abdominal pain, nausea, vomiting, diarrhea, constipation, or GI bleeding.

· Genitourinary: No dysuria, hematuria, incontinence, or frequency.

· Musculoskeletal: Reports arthritis; no new joint pain, swelling, or muscle weakness.

· Integumentary (Skin): No rashes, lesions, or pruritus.

· Neurological: Status post brain surgery (2012); no new weakness, numbness, headaches, seizures, or memory loss.

· Psychiatric: Reports lifelong anxiety, recent onset depression/grief, emotional lability, tearfulness; denies suicidal/homicidal ideation, psychosis, mania, or compulsions.

· Hematologic: No bleeding, bruising, or history of blood disorders.

· Lymphatic: No lymphadenopathy or unexplained swelling.

· Endocrine: Uses estradiol cream; no symptoms of thyroid dysfunction (heat/cold intolerance, hair loss, changes in appetite, or unexplained weight changes).

Objective:

· Diagnostic results:

· Basic Metabolic Panel (BMP) and Complete Blood Count (CBC): Recommended to rule out metabolic derangements or anemia that may contribute to mood or cognitive symptoms (Atri et al., 2024)

· Thyroid Function Tests (TSH, Free T4): Abnormal thyroid function can present with depressive or anxiety symptoms, especially in older adults (Forbes et al., 2025).

· Vitamin B12 and Folate Levels: Deficiencies can mimic or exacerbate neuropsychiatric symptoms (Atri et al., 2024)

· Urinalysis and Renal Function: Particularly important given her history of kidney stones and age (Bhojani et al., 2022).

· Cognitive Screening (e.g., MMSE or MoCA): While she currently shows no signs of cognitive impairment, routine screening may be considered given her age and psychiatric presentation (S. Zhang et al., 2021).

· Recent physical exam: No abnormal labs

· No acute findings on review

Assessment:

The patient is a 66-year-old Caucasian female who appears her stated age. She is well-groomed, clean, and appropriately dressed. With no evidence of abnormal motor activity or psychomotor agitation. Her attitude is cooperative , and she engages readily with the examiner . Speech is clear, coherent, and normal in rate, tone, and volume throughout the session. Her mood is described as generally euthymic but she becomes tearful at times when discussing recent losses and stressors. Her affect is full in range and congruent with the content of conversation . Thought processes are logical and goal-directed , and her associations are intact . She exhibits no signs of loosening of associations, tangentiality, or flight of ideas . Thought content reveals no suicidal or homicidal ideation, and no evidence of psychosis, paranoia, or delusional thinking . The patient denies auditory or visual hallucinations , and there are no perceptual disturbances such as illusions or pseudohallucinations observed or reported . She is alert and oriented to person, place, and time . Recent and remote memory are intact , and she demonstrates good attention and concentration during the interview . Insight and judgment are both good , and her fund of knowledge is appropriate for her background and education.

Diagnostic Impression

1. Major Depressive Disorder (MDD), Recurrent, Moderate (F33.2)

Based on R.B’s recent onset of depressed mood , frequent crying spells , fatigue , hopelessness, and marked anhedonia with impaired daily functioning. She has a documented history of depressive episodes triggered by significant life stressors and losses. She currently denies suicidal ideation and psychotic symptoms . This primary diagnosis is supported by DSM-5-TR criteria, which require at least two weeks of persistent depressed mood or loss of interest plus other symptoms; R.B.’s presentation and moderate functional impairment align with this standard, and her pattern of recurrent episodes further substantiates the diagnosis (Ding et al., 2022).

2. Generalized Anxiety Disorder (GAD) (F41.1)

R.B.’s presentation aligns with Generalized Anxiety Disorder due to her lifelong pattern of excessive, difficult-to-control worry, accompanied by restlessness, irritability, muscle tension, and difficulty relaxing, without evidence of panic attacks, obsessive-compulsive behaviors, or phobias. Neurobiological evidence shows that persistent worry manifests as distinct functional connectivity patterns across key brain networks—including the default mode and salience networks—which supports the validity of GAD as a discrete syndrome (Gerlach et al., 2021). Moreover, GAD is recognized as the most prevalent anxiety disorder in older adults and is defined by chronic, pervasive worry over at least six months with associated physical and cognitive symptoms, matching her symptom profile (Gerlach et al., 2021).

4. PTSD (Chronic, not formally diagnosed)

R.B.’s clinical presentation marked by multiple traumatic losses, chronic grief, intrusive memories, avoidance, and hyperarousal, yet lacking psychotic features or acute dissociation strongly aligns with chronic PTSD, albeit undiagnosed. A 2021 study of older U.S. veterans found that both subthreshold and full PTSD are common and are associated with elevated rates of depression, suicidality, and functional impairment (Moye, Kaiser, Cook, Pietrzak, 2021). Moreover, a 2021 meta-analysis demonstrated a high prevalence of post-traumatic stress symptoms co-occurring with prolonged grief in bereaved adults, supporting the plausibility of a chronic PTSD presentation in the context of cumulative losses (Komischke-Konnerup et al., 2021).

5. Grief and Loss

R.B. has experienced significant bereavement including the losses of her daughter, partner, and others with ongoing mourning that clearly impacts her mood and overall well-being. While her grief is pervasive, there is no evidence of complicated or prolonged grief disorder, as symptoms have not persisted beyond expected cultural norms or reached the threshold for a separate diagnosis. This aligns with recent evidence showing that many older adults experience sustained, impactful grief following major losses, but do not necessarily develop pathological grief syndromes (Robinson et al., 2026).

Reflection

Reflecting on this case, I concur with my preceptor’s diagnostic impression: the patient’s history and symptom profile warrant diagnoses of recurrent moderate MDD, GAD, and insomnia, with strong evidence for chronic PTSD and pervasive grief (Baltjes, Cook, Van Kordenoordt, & Sobczak, 2023). This case underscores the importance of trauma-informed care in older adults facing complex psychiatric and medical challenges, as trauma, grief, and psychiatric symptoms are deeply intertwined and demand nuanced assessment and treatment. I recognize the value of considering comorbidities, resilience, and support systems in care planning, and would advocate for formal PTSD assessment and exploration of targeted interventions like EMDR, TMS, and peer support for grief, in line with best practices. Ethical care requires vigilance around professional boundaries, capacity and consent, confidentiality—particularly given the patient’s dual role as a therapist, and proactive end-of-life and advance care planning, as recommended in recent geriatric psychiatry literature (Baltjes et al., 2023). Older adult women face increased risk for depression and anxiety, making regular mental health screening and age-appropriate interventions essential (World Health Organization: WHO, 2025). The patient’s strong social support system, access to care, and professional background serve as protective factors, promoting resilience and positive health outcomes. Culturally sensitive care honoring her values and beliefs around grief, loss, and family is critical for effective engagement and support (Van Vleet et al., 2025). Health promotion should focus on ongoing therapy, maintining social connections, physical activity, and sleep hygiene, while also closely monitoring for polypharmacy and potential drug interactions, which are common risks in older adults. Preventive strategies include routine screening for cognitive decline, substance use, and suicidality, all of which are more prevalent in this population and can significantly affect quality of life (Van Vleet et al., 2025).

Case Formulation and Treatment Plan:

The patient’s current stability and recent unremarkable labs justify deferring acute diagnostic studies, though it remains standard of care to obtain a baseline metabolic panel and CBC before initiating or adjusting psychotropic medications, especially in older adults to monitor for metabolic, hematologic, or renal risks (Atri et al., 2024b). Annual thyroid function monitoring is also prudent, given the relationship between thyroid abnormalities and mood/cognitive disorders in this population. Referrals emphasize continued psychotherapy (CBT, trauma-focused/EMDR and TMS), grief support, and primary care follow-up for comorbidities, with neurology input as needed. Treatment for MDD includes Auvelity and Brexpiprazole (with clear education on risks, benefits, and withdrawal symptoms) and augmentation with psychotherapy as needed, while GAD and insomnia are managed primarily through non-pharmacologic means, minimizing benzodiazepine use due to the elderly’s increased sensitivity and risk profile (Gerlach et al., 2021). Trauma-focused therapy, supportive counseling, and encouraging social support and healthy lifestyle habits address PTSD, grief, and overall wellness. Medication safety is prioritized, with education about potential interactions and the dangers of alcohol or illicit substances. Health promotion includes fostering regular exercise, social engagement, and vigilant monitoring for polypharmacy and adverse drug reactions. The plan is to maintain outpatient management with close follow-up in four weeks, underscoring the value of a proactive, multidisciplinary, and patient-centered approach in geriatric mental health care.

 

PRECEPTOR VERFICIATION:

I confirm the patient used for this assignment is a patient that was seen and managed by the student at their Meditrek approved clinical site during this quarter course of learning.

Preceptor signature: ________________________________________________________

Date: ________________________

References

Atri, A., Dickerson, B. C., Clevenger, C., Karlawish, J., Knopman, D., Lin, P., Norman, M., Onyike, C., Sano, M., Scanland, S., & Carrillo, M. (2024). Alzheimer’s Association clinical practice guideline for the Diagnostic Evaluation, Testing, Counseling, and Disclosure of Suspected Alzheimer’s Disease and Related Disorders (DETeCD‐ADRD): Executive summary of recommendations for primary care. Alzheimer S & Dementia, 21(6), e14333. https://doi.org/10.1002/alz.14333

Baltjes, F., Cook, J. M., Van Kordenoordt, M., & Sobczak, S. (2023). Psychiatric comorbidities in older adults with posttraumatic stress disorder: A systematic review. International Journal of Geriatric Psychiatry, 38(6), e5947. https://doi.org/10.1002/gps.5947

Bhojani, N., Bjazevic, J., Wallace, B., Lee, L., Kaler, K. S., Dion, M., Cowan, A., Sultan, N., Chew, B. H., & Razvi, H. (2022). Update – 2022 Canadian Urological Association guideline: Evaluation and medical management of the kidney stone patient. Canadian Urological Association Journal, 16(6), 175–188. https://doi.org/10.5489/cuaj.7872

Ding, Y., Chen, X., Chen, Z., Li, L., Li, X., Castellanos, F. X., Bai, T., Bo, Q., Cao, J., Chang, Z., Chen, G., Chen, N., Chen, W., Cheng, C., Cheng, Y., Cui, X., Duan, J., Fang, Y., Gong, Q., . . . Guo, W. (2022). Reduced nucleus accumbens functional connectivity in reward network and default mode network in patients with recurrent major depressive disorder. Translational Psychiatry, 12(1), 236. https://doi.org/10.1038/s41398-022-01995-x

Forbes, M., Watson, T., Topliss, D. J., Lotfaliany, M., Mohebbi, M., Woods, R. L., McNeil, J. J., & Berk, M. (2025). Thyroid-Stimulating hormone levels and depression in Older Adults: Cross-Sectional and Longitudinal analyses in a Community-Dwelling population. American Journal of Geriatric Psychiatry, 34(4), 544–554. https://doi.org/10.1016/j.jagp.2025.02.012

Gerlach, A. R., Karim, H. T., Kazan, J., Aizenstein, H. J., Krafty, R. T., & Andreescu, C. (2021). Networks of worry—towards a connectivity-based signature of late-life worry using higher criticism. Translational Psychiatry, 11(1), 550. https://doi.org/10.1038/s41398-021-01648-5

Komischke-Konnerup, K. B., Zachariae, R., Johannsen, M., Nielsen, L. D., & O’Connor, M. (2021). Co-occurrence of prolonged grief symptoms and symptoms of depression, anxiety, and posttraumatic stress in bereaved adults: A systematic review and meta-analysis. Journal of Affective Disorders Reports, 4, 100140. https://doi.org/10.1016/j.jadr.2021.100140

Moye, J., Kaiser, A. P., Cook, J., & Pietrzak, R. H. (2021). Post-traumatic stress disorder in older U.S. military veterans: prevalence, characteristics, and psychiatric and functional burden. American Journal of Geriatric Psychiatry, 30(5), 606–618. https://doi.org/10.1016/j.jagp.2021.10.011

Robinson, L., Smith, M., MA, Robinson, L., & Smith, M., MA. (2026, June 22). Bereavement: grieving the loss of a loved one. HelpGuide.org. https://www.helpguide.org/mental-health/grief/bereavement-grieving-the-death-of-a-loved-one

World Health Organization: WHO. (2025, October 8). Mental health of older adults. https://www.who.int/news-room/fact-sheets/detail/mental-health-of-older-adults?utm_source=openai

Van Vleet, R., Chitwood, S., Hallman, V., Heffernan, M., Fromknecht, C., O’Leary, M., Lin, Y., & Hoyer, D. (2025). Community-Level Strategies for Addressing Disparities in Healthy People 2030 Leading Health Indicators. Journal of Public Health Management and Practice, 31(3), 440–446. https://doi.org/10.1097/PHH.0000000000002097

Zhang, S., Qiu, Q., Qian, S., Lin, X., Yan, F., Sun, L., Xiao, S., Wang, J., Fang, Y., & Li, X. (2021). Determining appropriate screening tools and cutoffs for cognitive impairment in the Chinese elderly. Frontiers in Psychiatry, 12, 773281. https://doi.org/10.3389/fpsyt.2021.773281