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Carline Timothee

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Psychotic Features Discussion Essay

Carline Timothee:Walden University:NRNP-6675 PMHNP-Care Across the Lifespan II Practicum Robert Daun,RN,DMP:7/26/2023

Assessing a Patient with Depressive Symptoms

Objective1. Find three differential diagnoses for the older Adult patient.2. Diagnostic criteria for an older adult patient with major depressive disorder.3. Choose evidence-based pharmacological and non-pharmacological treatment interventions for an older adult with major depressive disorder.(Psychotic Features Discussion Essay)

Patient Initials: L.L.Gender: FemaleAge: 65 yearsSUBJECTIVE:CC: “I have difficulty sleeping, and my daughter recommended I see a therapist and make an appointment.”(Psychotic Features Discussion Essay)

HPI: L.L., a 65-year-old female patient, visits the clinic accompanied by her son, complaining of difficulty sleeping. The patient is here because her daughter advised her to see a therapist and booked an appointment for her. She reports pervasive low self-esteem, attributed to her marriage. The patient states the husband is mentally abusive and cheats on her with multiple women. She has not left her marriage because she did not want the children to grow up without both parents. The children are all grown now and do not live with her anymore. She reports sleeping issues, restlessness, increased irritability, forgetfulness, anxiety, loneliness, and shaking. She engages in(Psychotic Features Discussion Essay)

binge eating during her loneliness at times. The patient does not feel like going out anymore and does not call her friends. She feels helpless and hopeless.Social History: The patient lives with her husband, who is often not home. Her children moved out, and she now feels lonely. She has three children, all grown.

Education and Occupation History: Secretary.Substance Current Use and History: The client denies any history of substance abuse. Legal History: The client denies any legal history.Family Psychiatric/Substance Use History: The patient reports that her father was an emotionally defiant child, and her paternal aunt had schizophrenia. Her mother experienced physical abuse from her father, raising four children alone.(Psychotic Features Discussion Essay)

Past Psychiatric History:

Hospitalization: Denies previous hospitalization.Medication trials: Denies history of medical trialsPsychotherapy or Previous Psychiatric Diagnosis: Denies previous psychiatric evaluation(Psychotic Features Discussion Essay)

Medical History: She has diabetes and hypertension. She has always had a weight problem.

Current Medications: Metformin 500 mg PO. BID, Metoprolol 50 mg PO daily. Allergies: Denies allergic reactions. NKA.Reproductive Hx: Rarely has sex with her husband, who is emotionally unavailable and abusive. The patient reports normal birth and normal babies.(Psychotic Features Discussion Essay)

ROS:

• • •

General: States progressive weight gain and reports feeling tired and weak. The patient denies fever.HEENT: Eyes: Patient denies visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.(Psychotic Features Discussion Essay)

Skin: No rash or itching.Cardiovascular: Denies chest pain, chest pressure, or chest discomfort. No palpitations or edema.Respiratory: Denies wheezes, shortness of breath, consistent coughs, and breathing difficulties while resting.Gastrointestinal: The patient reports diet changes and binge eating when she feels lonely. She denies feelings of nausea and vomiting. Denies diarrhea. No abdominal pain or blood. The patient reports experiencing constipation.Genitourinary: Denies burning on urination, urgency, hesitancy, odor, and odd color. Neurological: She has frequent headaches, denies dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. Reports no change in bowel or bladder control. Reports concentration and attention difficulties and forgetfulness.Musculoskeletal: The patient occasionally experiences muscle pain and weakness. The patient reports back pain when doing home chores and denies muscle or joint stiffness. Hematologic: Denies anemia, bleeding, or bruising.Lymphatics: Denies enlarged nodes. No history of splenectomy.(Psychotic Features Discussion Essay)

Endocrinologic: Denies sweating. No reports of cold or heat intolerance. No polyuria or

polydipsia.

OBJECTIVE: Vital signs: Stable Temp: 97.9F

B.P.: 125/80 P: 85

R.R.: 17O2: Room air Pain: 2/10Ht: 5’0 feetWt: 230 lbsBMI: 44.9BMI Range: Obese

LABS:

Physical Exam:General appearance: The patient appears well-groomed and dressed. She appears overweight, as evidenced by her BMI. The patient is polite and regularly engaged with(Psychotic Features Discussion Essay)

Lab findings WNL Tox screen: Negative Alcohol: Negative(Psychotic Features Discussion Essay)

the interviewer. She appears depressed, uninterested, and anxious at some point. She has problems focusing on the interview and appears restless.HEENT: Normocephalic and atraumatic. Sclera anicteric, No conjunctival erythema, PERRLA, oropharynx red, moist mucous membranes.(Psychotic Features Discussion Essay)

Neck: Supple. No JVD. Trachea midline. No pain, swelling, or palpable nodules. Heart/Peripheral Vascular: Regular rate and rhythm noted. No murmurs. No palpitation. No peripheral edema to palpation bilaterally.Cardiovascular: The patient’s heartbeat and rhythm are normal. The patient’s heart rate is within normal range, and capillaries refill within two seconds.

Musculoskeletal: Normal range of motion. Regular muscle mass for age. No signs of swelling or joint deformities. Muscle and back pain rated 2/10.Respiratory: Faint wheezes are noticeable, but respirations are easy and regular. Neurological: Balance is stable, gait is normal, posture is erect, the tone is good, and speech is clear. The patient has frequent headaches. She has problems concentrating and focusing on the interview. She has short-term memory problems and is restless and uninterested in the interview.(Psychotic Features Discussion Essay)

Psychiatric: The patient appears depressed, worn-out, irritability at times and indicates impaired concentration and attention.Neuropsychological testing: Her socio-emotional functioning is impaired. Behavior/motor activity: The patient demonstrated appropriate behavior throughout the assessment(Psychotic Features Discussion Essay)

Gait/station: Stable.

Mood: Depressed mood.Affect: The patient has a depressed mood.Thought process/associations: The patient has a comparatively linear and goal-oriented thought process.Thought content: The patient has appropriate thought content.Attitude: The patient appeared uninterested at timesOrientation: The patient is oriented to self, place, situation, and general timeframe. Attention/concentration: She indicates impaired attention/concentrationInsight: Her insights are goodJudgment: Her judgment is goodRemote memory: Her remote memory is fair; she reports forgetfulness, and her short- term memory is fair. She indicates good intellectual/cognitive function. She has clear speech and a normal tone. The patient’s fund of knowledge is good. Denies suicidal ideation. Denies homicidal ideation.Short-term memory: Her short-term memory is fairIntellectual /cognitive function: She indicates good intellectual/cognitive function. Language: She has clear speech and a normal toneFund of knowledge: The patient’s fund of knowledge is goodSuicidal ideation: Denies suicidal ideation.Homicide ideation: Denies homicidal ideation.(Psychotic Features Discussion Essay)

ASSESSMENT:Mental Status Examination:

The 65-year-old female patient reports experiencing sleeping difficulties since her children moved out. She feels lonely, helpless, and hopeless. She is forgetful and indicates restlessness and irritability. The patient demonstrated appropriate behavior throughout the assessment. Her gait is stable, but she appears depressed. The patient has an appropriate thought content. The patient appeared uninterested at times. The patient is oriented to self, place, situation, and general timeframe. She indicates impaired attention/concentration. Her insights are good. Her judgment is good, her remote memory is fair, she reports forgetfulness and her short- term memory is fair. She indicates good intellectual/cognitive function. She has clear speech and a normal tone. The patient’s fund of knowledge is good. She denies suicidal and homicidal ideation.Differential Diagnosis:(Psychotic Features Discussion Essay)

1. F32.9 Major Depressive Disorder

The patient shows signs of major depressive disorder. She reports sleeping difficulty, increased anxiety, and low self-esteem. The patient reports feeling lonely, helpless, and hopeless. Additionally, she is easily irritated and has no interest in going out with or calling her friends. She reports being restless, forgetful, and shaking at times. The patient reports being mentally abused by her husband, who cheats on her with multiple women.(Psychotic Features Discussion Essay)

Moreover, the patient reports increased appetite during her lonely times and weight gain. The DMS-5 criteria for MDD requires a patient to demonstrate five of the following indications, including sleeping difficulties, less interest in previously enjoyable activities, feeling inadequate and helpless, atypical fatigue and energy, attention and concentration difficulties, weight and

appetite changes, psychomotor challenges, suicidality, and a low mood (Chand et al., 2021). L.L. indicates at least five symptoms, confirming the major depressive disorder.(Psychotic Features Discussion Essay)

2. F40. 10 Social Anxiety Disorder (SAD)

The patient shows signs of social anxiety disorder. The patient spends more time alone since her children no longer live with her. She reports feeling lonely, but at the same time, she is uninterested in going out and socializing like she used to. She also says she no longer calls her friends. The patient reports increased anxiety during this period. The patient has decreased self- esteem. Social anxiety disorder is a common comorbidity of MDD, as most patients assessed for MDD report decreased interest in socializing and increased anxiety and concern over what other people will think of them. They fear judgment and report low self-esteem. According to Langer et al. (2019), 44% and 74% of people with SAD develop MDD at some point. Per the DMS-5 criteria, a person diagnosed with SAD must have fear or anxiety in a social situation where they may attract attention from others and probable observation. The individuals fear judgment or their character being misconstrued. These people develop anxiety during social activities and indicate excessive fear, which would be typical in such a situation. This anxiety lasts less than six months until the patients are almost entirely avoidant and fearful, significantly affecting their functioning. This fear should not be attributed to another mental condition like substance abuse (Rose & Tadi, 2021). L.L. reports increased anxiety and reduced interest in going out or calling her friends, but she does not fit the SAD criteria; hence the diagnosis was refuted.(Psychotic Features Discussion Essay)

3. F50.81 Binge Eating Disorder:

The patient shows signs of binge eating disorder. She reports that she has always had problems with weight. However, lately, she has written about overeating when alone at the(Psychotic Features Discussion Essay)

house. MDD often co-occurs with eating disorders, including binge eating, which is linked to psychological issues and a particular degree of impairment in daily life. She reports an increased appetite and weight gain. Per the DMS-5 criteria, for a person to be diagnosed with binge eating disorder, they must be consuming extreme amounts of food than an average person would be able to in similar circumstances and time and must lack control over their eating and feel guilty after eating (Iqbal & Rehman, 2022). Episodes must occur weekly, at least once a week for about three months, and should not be linked to compensatory disorder. The patient reports eating a lot due to loneliness, but her symptoms are inadequate to establish a binge eating disorder. More evaluation and data are needed to confirm a diagnosis.(Psychotic Features Discussion Essay)

Plan:

Safety Risk/Plan:

The patient reports no suicidal or homicidal ideation. She does not engage in self-harm, but eating a lot when lonely is a health risk factor that the patient needs to address. She does not require hospitalization.Pharmacological Interventions:

The patient indicates depressive symptoms that can be treated using antidepressants like selected serotonin reuptake inhibitors, including fluoxetine and citalopram, which should be used as first-line treatment (Chand et al., 2021). Antipsychotics and mood stabilizers can be prescribed to increase the effectiveness of antidepressants and attain optimal health outcomes like improved mood, increased energy and motivation, reduced anxiety, and increased perception of self.(Psychotic Features Discussion Essay)

Fluoxetine 10 mg po daily order, F/U in two weeks.

The patient would benefit from combining medication and psychotherapy.

Psychotherapy:

The patient will benefit significantly from psychotherapies. First, the patient requires couple therapy to address her problems with her husband, who is emotionally abusive and unavailable, cheating on her with multiple women. Couple therapy would help develop a solution, which might include divorce. The patient will also benefit from cognitive behavioral and talk medicines that address problematic behavioral and thought patterns and self-perception (Chand et al., 2021). Cognitive behavioral therapy can help the patient develop desired behaviors like eating healthily, exercising, and increasing social activity. It can also help correct thought patterns and improve self-perception. Additionally, family therapy involving parents and children will help address relationship problems between family members and mend broken communication links to foster a supportive family environment.(Psychotic Features Discussion Essay)

Education:

  1. The patient should learn about the side and potential adverse effects, like the drug interactivity of the prescribed medications.
  2. The patient should be advised to be consistent with therapy for optimal outcomes.
  3. The patient should be educated on developing meal plans and exercise routines tomanage her weight.
  4. The patient should be advised to follow prescriptive instructions.
  5. The patient should be advised to engage in group therapy or sessions to enhancesocial skills.

Consultation/follow-up: The patient should return to the clinic after two weeks for further assessment.

Reflection:

The interview was successful, leading to adequate data required to develop an accurate diagnosis of the patient and a treatment plan. This activity presents a clear case of a patient experiencing depressive symptoms attributed to her life experiences, familial relationships, and self-perception. The patient indicates issues with sleeping and feeling lonely because she no longer lives with her children. She has low self-esteem, and she feels helpless and hopeless. Her husband is emotionally absent and cheats on her with multiple women. Most parents, especially those whose spouses are emotionally unavailable or abusive, experience loneliness when their children are grown and do not live with them anymore. Mothers are more emotionally attached to their children than most fathers; hence, they are more likely to experience loneliness or coping difficulties when their children leave. A lack of a supporting spouse or social environment exacerbates these feelings and can contribute to depression and anxiety, as indicated in this case. This activity offers valuable insights into the unique way MDD develops and the importance of environmental factors in the development of MDD. In another encounter with the patient, I would inquire more about her daily life and activities, coping mechanisms, and relationship with her children and call in the husband for a comprehensive assessment.(Psychotic Features Discussion Essay)

Working with patients experiencing depressive symptoms requires sensitivity, empathy, and compassion to make them feel valued and heard. The practitioner should treat the patient with respect and dignity, considering most report self-esteem issues. Additionally, the practitioner should actively listen to the patient and provide meaningful feedback to encourage patient engagement. This patient reports multiple health problems, and several health-promoting initiatives are recommended, including going out more and engaging with friends, developing(Psychotic Features Discussion Essay)

meal plans and cooking healthy meals full of fruits, proteins, and vegetables, and less in fats and carbohydrates, increasing physical activity and exercising more to reduce and manage weight, and finding hobbies or activities she might like now that her children are no longer in the house.(Psychotic Features Discussion Essay)

Discussion /Question.

Suppose you are the provider for this Patient! What would be your plan to manage this patient? Pharmaceutical and Non-Pharmaceutical intervention.

2. What would be The advice to give this patient about her weight? And her health Continuum?

3. What other treatment plan suggestions, Do you have for this patient? 4. Do you support this diagnosis?

References

Chand, S. P., Arif, H., & Kutlenios, R. M. (2021). Depression (Nursing). In: StatPearls [Internet]. StatPearls Publishing.

Iqbal, A., & Rehman, A. (2022). Binge Eating Disorder. In StatPearls. StatPearls Publishing. Langer, J. K., Tonge, N. A., Piccirillo, M., Rodebaugh, T. L., Thompson, R. J., & Gotlib, I. H.

(2019). Symptoms of social anxiety disorder and major depressive disorder: A network perspective. Journal of affective disorders, pp. 243, 531–538. https://doi.org/10.1016/ j.jad.2018.09.078

Rose, G. M., & Tadi, P. (2021). Social anxiety disorder. In StatPearls [Internet]. StatPearls Publishing.

Psychotic Features Discussion Essay-Solution

Response to colleague

Response to Cecilia Severino

Hello Severino,

Thank you for taking the time to read and respond to my patient assessment note. I have learned a lot from your perspectives, and sure will consider these insights in my future patient assessments and development of treatment plans. We agree that the presented symptoms and the physical and mental assessments indicate major depressive disorder with psychotic features as the primary diagnosis. Regarding treatment, patients react differently to medication, and it is critical to continually assess any changes or adverse events after prescribing medications. Therefore, the impact of prescribed antidepressants depends on how the patient responds.(Psychotic Features Discussion Essay)

I appreciate the evidence you share regarding the effectiveness of antidepressants in managing and treating depression. Often, antidepressants play similar roles in treating depression. However, as asserted above, patients react differently to different medications, and it is critical to evaluate the patient’s previous and current medications and medical history to help make decisions about the appropriate medications. Additionally, mechanisms of action impact medication selection, and it would be appropriate to evaluate how the different antidepressants act to alleviate depressive symptoms before prescribing. I agree that citalopram, escitalopram, sertraline and paroxetine have almost similar effectiveness in addressing depression. Still, I would stress assessing patient factors that might impact how they react to the different medications.(Psychotic Features Discussion Essay)

I appreciate that you have also addressed age as influencing prescription and provided a relevant and valuable rationale. I agree that clinicians should be more careful when prescribing for older patients (Fialová et al., 2018). I recommend performing a risk assessment to determine potential adverse events, side effects, and drug interactions to develop a robust treatment plan and schedule for taking the different types of medications. My selection of cognitive behavioral therapy and interpersonal therapy was evidence-based. These modalities have demonstrated effectiveness in treating and managing depression and co-occurring conditions like psychosis and anxiety (Whiston et al., 2019). I am grateful for your response, which will contribute to my understanding of comprehensive patient assessment and diagnosis and treatment of mental illnesses.(Psychotic Features Discussion Essay)

References

Fialová, D., Kummer, I., Držaić, M., & Leppee, M. (2018). Ageism in medication use in older patients. International Perspectives on Aging, 213-240. https://doi.org/10.1007/978-3-319-73820-8_14

Whiston, A., Bockting, C. L. H., & Semkovska, M. (2019). Towards personalising treatment: a systematic review and meta-analysis of face-to-face efficacy moderators of cognitive-behavioral therapy and interpersonal psychotherapy for major depressive disorder. Psychological medicine49(16), 2657–2668. https://doi.org/10.1017/S0033291719002812

(Psychotic Features Discussion Essay)

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