Video wk 4 (scene 2)

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Provide a response 3 discussions prompts 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.

Responses exhibit synthesis, critical thinking, and application to practice settings…. Responses provide clear, concise opinions and ideas that are supported by at least two scholarly sources…. Responses demonstrate synthesis and understanding of Learning Objectives…. Communication is professional and respectful to colleagues…. Presenters’ prompts/questions posed in the case presentations are thoroughly addressed…. Responses are effectively written in standard, edited English.

So here are my questions:

1. what would be your primary diagnosis is

2. would Wellbutrin be your first choice of antidepressant? If not, why?

3. would you give a prn Vistaril that the pt can take up to 3 times as needed or once daily minimum dose is enough?

NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template

Week # 4: Case Study Presentation

Subjective: “I get anxious for no reason”

CC (chief complaint): “I think this visit is way overdue, I get anxious for no reason”. Pt states he gets frequently anxious to a point where he is afraid that he would get panic attack in a public place so, he often finds himself taking frequent breaks when at work because he doesn’t want his coworkers to see him if he gets a panic attack.


HPI: A.H. is a 35-yowm who presents to the clinic for an initial visit for psychiatric evaluation, med management, and treatment with history of anxiety. Patient is A&O x4, mood is normal, affect congruent with mood, speech and thought process are normal, cognition normal, pt appears anxious, fidgety and continuously tapping his right knee with his fore finger, he appears neat and well groomed. Speech is clear, eloquent and goal directed. Patient states “I think this visit is way overdue, I get anxious for no reason”. Pt states he gets frequently anxious to a point where he is afraid that he would get panic attack in a public place so, he often finds himself taking frequent breaks when at work because he doesn’t want his coworkers to see him if he gets a panic attack. He denies ever having a panic attack, denies hx of psychiatric illness/hospitalization.

He denies use of illicit drugs, no smoking but drinks a couple of beer at night “to take the edge off”. Had his first drink at age 15, he’s never been arrested, states he does not have any legal issues. Past medical history is Asthma, he has seasonal allergies and takes Claritin 10mg daily but he doesn’t think it does anything for him anymore. Mother had depression, grew up in Canton, Ga with his brother and parents. He is the oldest of two children, has a college degree, married with two boys and lives in Atlanta, Ga..

Denies hx of sexual/physical abuse, states “my brother and I got all the love possible, I think we were spoilt, my parents did an amazing job and I have a wonderful wife, I just can’t shake this nervousness off”. Depression is 3/10, anxiety rated 9-10/10. He states he first noticed the anxiety at 14yrs old but it was mild and he dealt with it by himself. No pressure at work, no changes to lifestyle, states he gets racing thoughts and unable to focus on a task, get intrusive thoughts occasionally and motivation to get things done is very low. He sleeps about 4-5 hrs appetite fluctuates. denies mood swings and irritability. Patient denies SI/HI/AH/VH. PHQ-9 is 7 and GAD is 15. Patient will start Wellbutrin 75mg by mouth once daily, hydroxyzine 10mg by moith once daily, CBC, Thyroid function test ordered.. Referral for psychotherapy provided, education about psychotropic use with alcohol/illicit/OTC drug use provided. Patient is scheduled for a f/p visit in 2 weeks.

Substance Current Use: He denies use of illicit drugs, no smoking but drinks a couple of beer at night “to take the edge off”. Had his first drink at age 15 and drinks a cup of tea every morning.

Medical History:

·
Current Medications: Claritin 10mg by mouth daily.

·
Allergies:
NKDA, Seasonal Allergies

·
Reproductive Hx:
A.H. is a male who is married with two children and sexually active with one partner, had a vasectomy

ROS:

· GENERAL: No weight loss reported, no fever, chills or wealness or fatigue reported

· HEENT: No facial asymmetry observed, no report of changes in vision, pain, blurred vision, no redness or flashes of lights specs, no glasses or contact lenses, no report of hearing deficit, ringing in ears, no pain, nor drainage. No nasal congestion, discharge, nosebleeds and no sore throat.

· SKIN: Skin is intact, dry and warm to the touch, skin color is usual for ethnicity, no rash, lumps or bumps, denies itching, dryness or hair loss. Nail bed is normal color, capillary refills less than 3 seconds

· CARDIOVASCULAR: No SOB, no chest pain, palpitation, chest tightness, edema, or activity intolerance.

· RESPIRATORY: No cough, SOB, no wheezing auscultated

· GASTROINTESTINAL: No c/o stomachache, no bloating, no indigestion, denies vomiting, nausea, or diarrhea, appetite fluctuates.

· GENITOURINARY: denies burning on urination, no abnormal color or odor. No urgency/frequency

· NEUROLOGICAL: Denies dizziness, no headaches, no numbness, or tingling in extremities. No changes in bowel routine.

· MUSCULOSKELETAL: No muscle pain, no back pain, no stiffness, moves all extremities well.

· HEMATOLOGIC: No anemia, no bleeding or bruising

· LYMPHATICS: No enlarged nodes

· ENDOCRINOLOGIC: Denies abnormal sweating, no cold or heat intolerance. No frequent urination or excessive thirst.

Objective:

Diagnostic results: CBC, CT scan, and Thyroid function test ordered. A.H. gave consent for EGD result from his PCP

Assessment:

Mental Status Examination:

A.H. is a 35-yowm who presents to the clinic for an initial visit for psychiatric evaluation, med management, and treatment with history of anxiety. Patient is A&O x4, mood is normal, affect congruent with mood, speech and thought process are normal, cognition normal, pt appears anxious, fidgety, and continuously tapping his right knee with his fore finger, he appears neat and well groomed. Speech is clear, eloquent and goal directed. Patient states “I think this visit is way overdue, I get anxious for no reason”. Pt states he gets frequently anxious to a point where he is afraid that he would get panic attack in a public place so, he often finds himself taking frequent breaks when at work because he doesn’t want his coworkers to see him if he gets a panic attack. He denies ever having a panic attack, denies hx of psychiatric illness/hospitalization.

A.H. states his mother had depression, he grew up in Canton, Ga with his brother and parents. He is the oldest of two children, has a college degree, and married with two boys and lives in Atlanta, Ga. He denies use of illicit drugs, no smoking but drinks a couple of beer at night “to take the edge off”. Had his first drink at age 15, he’s never been arrested, does not have any legal issues. Past medical history is Asthma, he has seasonal allergies and takes Claritin 10mg daily but he doesn’t think it does anything for him anymore. Denies hx of sexual/physical abuse, states “my brother and I got all the love possible, I think we were spoilt, my parents did an amazing job and I have a wonderful wife, I just can’t shake this nervousness off”.

Depression is 3/10, anxiety rated 9-10/10. He states he first noticed the anxiety at 14yrs old but it was mild and he dealt with it by himself. No pressure at work, no changes to lifestyle, states he gets racing thoughts and unable to focus on a task, get intrusive thoughts occasionally and motivation to get things done is very low. He sleeps about 4-5 hrs and appetite fluctuates. Denies mood swings and irritability. Patient denies SI/HI/AH/VH. PHQ-9 is 7 and GAD is 15. Medication reconciliation completed with patient and patient will start Wellbutrin 75mg by mouth daily, and Hydroxyzine 10mg by mouth daily. CBC, Thyroid function test ordered. Referral for psychotherapy provided, education about use of psychotropics with alcohol/illicit/OTC or herbal drug use provided, side effects of medication prescribed also provided. A.H. advised to call emergency department or go to the nearest emergency room in case of an emergency, crisis line (988) also provided to pt, he was instructed to call or text for support when in need and he verbalized understanding. Patient is scheduled for a f/p visit in 2 weeks.

Diagnostic Impression:



Anxiety Disorder, unspecified (F41.9) : Anxiety disorders is a type of psychiatric issues. It’s challenging to get through the day when you’re anxious. Sweating and a fast heartbeat are symptoms, along with feelings of unease, panic, and fear.Genetics and environment can be a risk factor and it is said to be common amongst women than men (Cleveland Clinic Medical Professional, 2020). Anxiety disorders are the most prevalent psychiatric disorder experienced by men. Untreated anxiety is a risk factor for suicidal ideation and other psychiatric diseases, such as depression. Men’s anxiety is common and has an impact, yet it is still widely disregarded in the field of men’s mental health. In general, males are said to have anxiety disorders at a lesser rate than women, however these sex disparities do not adequately capture the range and nuance of men’s experiences (Fisher et al., 2022). According to the DSM-5 criteria, the individual with anxiety worry excessively and does so more days than not for atleast 6 months and have minimum of 3 of the symptoms such as Restlessness or apprehensive or unease, being easily tired, difficulty concentrating or mind going blank, Irritability, muscle tension, sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep) (NIH, 2022). A.H.’s GAD score is 15 which indicates that he has severe anxiety and requires treatment.



Depression (F32.9): Depression, also referred to as major depression, major depressive disorder, or clinical depression, is a common but serious mood disorder. It is challenging for a person to carry out daily activities like sleeping, eating, and working when they are experiencing severe symptoms.

There are many different types of depression, some of which are triggered by specific conditions, and for the symptoms to be considered depressive, they must last for at least two weeks. Depression can affect people of any age, race, nationality, or gender. Despite the fact that both men and women can experience depression, women are more likely to have it diagnosed. Because males may be less inclined to notice, express, and seek care for their moods or mental diseases, men are more likely than women to suffer undiagnosed or untreated indicators of depression. Along with persistent melancholy, anxiety, or “empty” thoughts of despair or pessimism, depression symptoms can also include fatigue, a lack of energy, or a sense of slowness. They can also include discomfort, worry, or impatience as well as feelings of shame, worthlessness, or impotence (NIMH, 2022).

The DSM-5 states that in order to receive this diagnosis, a person must exhibit 5 or more of the symptoms listed below: Depressed mood, loss of interest in nearly all activities, unintentional weight loss, gain, appetite fluctuates, sleep disturbance (excessive or lack of sleep), agitation or retardation, fatigue, or low energy level, delusional guilt, inability to think clearly or concentrate, frequent thoughts of death, and symptoms that cause clinically significant distress or functional impairment in social, occupational, or other important areas are among the symptoms. A.H has low motivation, PHQ-9 is 7 which indicates that he has some mild depression going which psychotherapy or a combination with psychopharm will be needed to treat.



Attention Deficit hyperactive Disorder (ADHD) (F90.0): A developmental disorder known as ADHD is characterized by a persistent pattern of impulsivity, hyperactivity, and/or inattention. The daily tasks and interpersonal relationships of a person might be considerably hampered by ADHD symptoms. According to the DSM- 5 criteria, at least 5 of the ADHD symptoms must be present for a minimum of 6 months. ADHD starts in early childhood and can last into adolescence and adulthood.

A person may not receive a diagnosis of ADHD until adulthood if their family or teachers failed to detect it when they were younger, if they had a mild form of the disorder, or if they functioned rather well until they were confronted with the responsibilities of adulthood, particularly at work (NIH, 2021). A.H scored 54 in his BADDS questionnaire which meand he is it is possible that he has ADHD but not confirmed (Kakubo et al., 2018).



Case Formulation and Treatment Plan: . A.H. advised to call 911 in an emergency, a crisis line (899) provided, A.H. will start with psychotherapy in addition to medication. Test results from PCP requested A.H. was seen for a total of 45 minutes, during which time the following tasks were completed: active listening, gathering health information, initiating the treatment plan, and answering patient’s questions. Accessing the patient’s medical records was approved by the patient. The patient will start Wellbutrin 75mg by mouth daily, Hydroxyzine 10mg by mouth once daily as needed and to he and will follow up in 2 weeks.

References

Cleveland Clinic Medical Professional. (2020, December 17).
Anxiety disorders: Types, causes, symptoms & treatments. Cleveland Clinic. https://my.clevelandclinic.org/health/diseases/9536-anxiety-disorders

Fisher, K., Seidler, Z. E., King, K., Oliffe, J. L., & Rice, S. M. (2021). Men’s Anxiety: A Systematic Review.
Journal of Affective Disorders,
295, 688–702. https://doi.org/10.1016/j.jad.2021.08.136

Kakubo, S. M., Mendez, M., Silveira, J. D., Maringolo, L., Nitta, C., Silveira, D. X., & Fidalgo, T. M. (2018). Translation and validation of the brown attention-deficit disorder scale for use in Brazil: Identifying cases of attention-deficit/hyperactivity disorder among samples of substance users and non-users. cross-cultural validation study.
Sao Paulo Medical Journal,
136(2), 157–164. https://doi.org/10.1590/1516-3180.2017.0227121217

NIH. (2021).
Attention-deficit/hyperactivity disorder in adults: What you need to know. National Institute of Mental Health. https://www.nimh.nih.gov/health/publications/adhd-what-you-need-to-know

NIH. (2022).
Generalized anxiety disorder: When worry gets out of Control. National Institute of Mental Health. https://www.nimh.nih.gov/health/publications/generalized-anxiety-disorder-gad

NIH. (2022b).
Table 3.15, DSM-IV to DSM-5 generalized anxiety disorder comparison … DSM-IV to DSM-5 Generalized Anxiety Disorder Comparison.
https://www.ncbi.nlm.nih.gov/books/NBK519704/table/ch3.t15/

Provide a response 3 discussions prompts 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.

Responses exhibit synthesis, critical thinking, and application to practice settings…. Responses provide clear, concise opinions and ideas that are supported by at least two scholarly sources…. Responses demonstrate synthesis and understanding of Learning Objectives…. Communication is professional and respectful to colleagues…. Presenters’ prompts/questions posed in the case presentations are thoroughly addressed…. Responses are effectively written in standard, edited English.

So here are my questions:

1. what would be your primary diagnosis is

2. would Wellbutrin be your first choice of antidepressant? If not, why?

3. would you give a prn Vistaril that the pt can take up to 3 times as needed or once daily minimum dose is enough?

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