Week 9 Grand Rounds
College of Nursing-PMHNP, Walden University
PRAC 6675: PMHNP Across the Lifespan II
Prof. Demesia Brown
July 24, 2022
NRNP/PRAC 6675 Comprehensive Psychiatric Evaluation Template
CC (chief complaint): “I’m feeling awful, I need help”.
HPI: J.H is a 70 year old white female who presents for an initial psychiatric evaluation status post hospitalization after a recent suicidal attempt by overdosing on ambien 5mg pills. She denies any history of psychiatric diagnoses or psychiatric consults, however, she has needed to use a sleep aid since her husband died over a year ago. Since then she has experienced increasing thoughts of death and dying, loss of interests in hobbies, difficulty sleeping, increased fatigue and depressed mood on most days. She reports feeling increased isolation and loneliness since the pandemic and experiencing the deaths of a few friends and her husband have left her with “very little will to continue living”. She also discloses feelings of shame and guilt about her actions to hurt herself. She has no close family or support, only a stepson and they do not have a good relationship. She is experiencing difficulty falling asleep and staying asleep, along with poor energy, low mood and diminished appetite. She is currently taking fluoxetine 20mg daily as prescribed by her primary care physician and denies the presence of any auditory or visual hallucinations, suicidal/ homicidal ideations or plans, or side effects to any medications.
Past Psychiatric History: Denies.
Substance Use – Current and History: Does not drink any alcohol, smoke cigarettes or use illicit drugs.
Family Psychiatric/Substance Use History: No known family history.
Social History: J.H is a widow and was raised in Connecticut in a strict Jewish household with both parents and an older brother who is now deceased. She reports growing up in a loving environment. She is a retired educator has a masters degree in education and leadership. She has no biological children and no close family members or relatives. There is no reported legal problems and she denies any financial difficulties.
Medical History: Hypertension
Surgical History: Breast Augmentation in 2000
Current Medications: fluoxetine 20mg daily, Amlodipine 5mg QD, Daily multivitamin.
· Allergies: NKDA
· Reproductive Hx: She is menopausal
· GENERAL: diminished appetite, difficulty sleeping, denies any fever or noticeable weight loss.
· HEENT: No issues with vision or with hearing.
· SKIN: There is no reported rash or skin lesions.
· CARDIOVASCULAR: There is no reported palpitations or chest pain.
· RESPIRATORY: there are no reported issues with breathing.
· GASTROINTESTINAL: There is no report of nausea, vomiting or diarrhea.
· GENITOURINARY: denies any issues with urination.
· NEUROLOGICAL: No dizziness, weakness or issues with gait.
· MUSCULOSKELETAL: no difficulty with ambulation, joint pain or swelling.
· HEMATOLOGIC: denies anemia.
· ENDOCRINE: No thyroid issues or heat/cold intolerance
Vital Signs: Ht 5’4” Wt 135lbs, BMI 23.
Physical exam: Deferred
Diagnostic results :
PHQ-9 Score: 21 (Severe depression)
GAD -7 Score: 5 (Mild Anxiety)
Geriaritric Depression Scale (GDS-15) Score: 14 (Severe Depression)
CBC, CMP, vitamins, minerals and Thyroid Function Panel were all normal
The use of screening tools such as PHQ-9 is an effective screening tool utilized in assessing for the presence of depression in patients (Sun et al, 2020). Furthermore, use of the GDS is also recommended for J.H and is based on client self report and is well validated for use with older adults who are cognitively intact (Avasthi & Grover, 2018). Additionally, nutritional status has a critical role in the onset, severity and length of depression (Ekong & Iniodu, 2021). This information requires the evaluation of serum levels of viatmins and nutrition status to assess the cause of depression. An evalution of J.H’s thyroid function is also imperative to an appropriate assessment and diagnosis of this patient. A prudent practitioner would rule out the presence of hypothyroidism due to the previously established positive correlation between depression and hypothyroidism (Loh et al, 2019).
Mental Status Examination: J.H is a 70 year old white female who presents for an initial evaluation with psychiatry after hospitalization for a suicide attempt by overdose with ambien 5mg pills. She is properlyl groomed and appears younger than her stated age. She is cooperative with the interview and describes her mood as depressed and hopeless, she is tearful and has a sad affect which is congruent with mood and within normal range. She has clear speech with regular rate and rhythm and normal language. She has an organized thought process and content, she is alert and oriented to time, place, situation and date. She denies any suicidal/homicidal ideations, plans or intent. Recent memory is intact and the patient possesses fair judgement and insight.
Major Depressive Disorder (MDD), Severe (F 32.2) – this is the most fitting diagnosis for J.H based on the requirements contained in the Diagnostic and Statistical Manual of Mental Disorders (DSM-V). The patient reports depressed mood and hopelessness most days, recurrent thoughts of death and dying, difficulty sleeping, depleted energy, and loss of interest in hobbies (APA, 2013). The patient has been experiencing these symptoms for greater than 2 weeks, they have been present almost daily and at this stage of assessment and evaluation it is not better explained by any other psychiatric disorder.
Mood disorder due to another medical condition – this diagnosis is appropriate pending a comprehensive health assessment and physical and ruled out once results of labwork is received and analyze. However, evaluation of these results confirm that current symptoms are not caused by any medical conditions such as hormone imbalances, vitamins or mineral deficiencies (APA, 2013). This is not the most appropriate diagnosis for this patient, based on the criteria established in the DSM-V.
Sadness – though the patient’s symptoms can be linked to an event/events which triggered concern and distress (APA, 2013). It is evident that the client has clearly met the established criteria for MDD.
Plan for Treatment:
This patient is currently being prescribed fluoxetine 20mg daily by her primary care physician (PCP). Therefore, we will continue with fluoxetine since she denies any side effects to the medication. However, we will increase to 40mg daily, and then augment with trazodone 25mg at bedtime to address insomnia and effectively boost antidepressant therapy (Stahl et al, 2021). J.H can also benefit from intiatiation of psychotherapy, such as cognitive behavioral therapy (CBT). Specific utilization of Problem Solving Therapy (PST) is effective in reducing suicidal ideation in older patients diagnosed with MDD (Okolie et al, 2017). Furthermore, older adults greatly benefit from the use of a collaborative care model that integrates pharmacotherapy, psychotherapy, robust screening and community group based programs (Okolie et al, 2017). J.H will benefit greatly from community group programs to reduce feelings of isolation and loneliness and ultimately improve symptoms of depression.
It is important that a strong therapeutic alliance be formed with J.H because a solid relationship with the older patient is crucial to delivering effective care. This objective is accomplished by customizing age friendly services and settings geared to that population (Okolie et al, 2017). Furthermore, any genuine effort to bridge the generation gap by enquiring about coping styles, and understanding their interpretation of what they are experiencing, will set the foundation for a rewarding interaction.
American Psychiatric Association. (2013). Depressive Disorders. In Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author. doi:10.1176/appi.books.9780890425596.dsm01
Avasthi, A., & Grover, S. (2018). Clinical Practice Guidelines for Management of Depression in Elderly. Indian journal of psychiatry, 60(Suppl 3), S341–S362. https://doi.org/10.4103/0019-5545.224474
Ekong, Moses B., &. Iniodu, Clementina, F. (2021). Nutritional therapy can reduce the burden of depression management in low income countries: A review. IBRO Neuroscience Reports, 11(15–28), 15–28. https://doi.org/10.1016/j.ibneur.2021.06.002
Loh, H.H., Lim, L.L., Yee, A., & Loh, H.S. (2019). Association between subclinical hypothyroidism and depression: an updated systematic review and meta-analysis. BMC Psychiatry, 19(1), 1–10. https://doi.org/10.1186/s12888-018-2006-2
Okolie, C., Dennis, M., Simon Thomas, E., & John, A. (2017). A systematic review of interventions to prevent suicidal behaviors and reduce suicidal ideation in older people. International psychogeriatrics, 29(11), 1801–1824. https://doi.org/10.1017/S1041610217001430
Stahl, S. M., Grady, M. M., & Muntner, N. (2021). Trazodone. In Stahl’s essential psychopharmacology: Prescriber’s Guide (7th edition). Cambridge University Press.
Sun, Y., Fu, Z., Bo, Q., Mao, Z., Ma, X., & Wang, C. (2020). The reliability and validity of PHQ-9 in patients with major depressive disorder in psychiatric hospital. BMC psychiatry, 20(1), 474. https://doi.org/10.1186/s12888-020-02885-6
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