PRAC 6675 Week (# 9): RESPONSE TO COLLEAGUE NO 2 SIMONE, Grand Rounds Discussion POST NO 1

******PLEASE ANSWER TO MY COLLEAGUE Simone G, DISCUSSION POST BELOW BY ANSWERING THIS QUESTION NO 1*****
Question no 1

what contributing factors affect patients who have psychiatric disorders and chronic medical disorders and diseases?

Week 9 Grand rounds discussion: complex case study presentation

College of Nursing-PMHNP, Walden University
PRAC 6675: PMHNP Care Across the Lifespan II
Dr. Ashley Lockhart
April 28, 2022

Subjective:
CC: “I just can’t seem to do too much in one day.”
HPI: Pt. reports increased depressed mood and irritability since her niece was recently murdered.
Substance Current Use: Pt. denies current or past substance use.
Medical History:

• Current Medications: Prevastatin 20mg po daily, amlodipine/benazepril HCL 10-40mg po daily, Keppra 500mg po daily, Lansoprazole 30mg po daily, Xtampa ER 13.5mg po daily, Percocet 10-325mg po BID, Gabapentin 300mg po TID, Cyclobenzaprine HCL 10mg po TID prn.
• Allergies: NKDA
• Reproductive Hx: Two living children, s/p menopause.
Psychiatric history: No reported inpatient hospitalizations, pt. is currently in psychotherapy. Denies any previous psychiatric medication trials. Current psychiatric medications: Latuda 40mg po daily, Sertraline 100mg po daily, Buspar 10mg po BID, Trazadone 100mg po qhs.
Substance abuse history: denies any illicit drug use or EtOH.
Legal history: Pt. denies any current or past legal problems.
Family psychiatric/substance abuse history: Unknown
Medical history: hyperlipidemia, seizure disorder, HTN, DM, chronic back pain, morbid obesity, GERD, hypothyroid, UTI
Surgical history: hysterectomy, eye surgery, prosthetic arthroplasty
Social history: Pt. is a single woman who lives alone. She has 2 adult children. She completed high school up to the 11th grade. She denies

ROS:
• GENERAL: Appears well-nourished, appearance unremarkable
• HEENT: no eye, ear, or nasal drainage, hearing intact. Denies any impairments or difficulties.
• SKIN: Intact, no abnormalities observed or reported
• CARDIOVASCULAR: No edema, no chest pain or discomfort reported
• RESPIRATORY: SOB with activity, current smoker
• GASTROINTESTINAL: No N/V/D reported, no distress observed
• GENITOURINARY: Denies difficulty voiding, no pain or discomfort reported
• NEUROLOGICAL: Denies headache, A/OX4, speech clear.
• MUSCULOSKELETAL: Ambulates with a seated rolling walker, reports right hip pain, gait steady and independent with the walker.
• HEMATOLOGIC: no visible bruising, denies bleeding
• LYMPHATICS: no neck, no upper or lower extremity edema
• ENDOCRINOLOGIC: denies heat or cold intolerance

Objective:
Diagnostic results: Most recent labs normal, lipids stable. Pt. reports she will need surgery on her right hip. No other diagnostic tests or imaging are available at this time.

Assessment:
Mental Status Examination: Appearance appropriate, appears younger than stated age. Pt. is obese. A/OX4, speech clear, normal rate and volume. Maintains good eye contact. The mood is depressed, and the affect is congruent to the mood. Pt. is tearful when speaking of the loss of her niece. She rates her depression is 7/10, decreased energy and motivation, and denies SI/HI. Pt. states her mood is irritable and she has crying spells.

Pt. endorses her appetite has diminished, sleep is interrupted at times, usually does not feel well rested in the morning. She rates her anxiety 7/10, due to thinking about how her niece was murdered, her last thoughts, and being unable to find closure at this time, no panic attacks were reported. Pt. denies A/VH, no disorganized thoughts or behaviors were observed.

The thought process is logical and linear. Insight and judgment are good related to her mental diagnosis and treatment plan.

Diagnostic Impression:
Bipolar I disorder, current episode depressed, severe meet criteria based on the client’s depressed mood most of the day, irritability, insomnia, fatigue, poor concentration, and lack of interest to engage in any activities. Comorbid physical and psychiatric illnesses are common and patients with bipolar disorder are at increased risk compared to the general public.

Patients with bipolar disorder should be screened for medical comorbidities such as inflammatory diseases, and endocrine disorders, and should be assessed and treated in concert (Rolin et al, 2020).

GAD meets DSM-V criteria based on the pt. feeling on edge, irritable, feeling tired often, and sleep disturbance. The client’s anxiety has been exacerbated by her trying to find closure for her niece’s death and worrying about what she was thinking before she died. The client appears to be a heavy smoker, which is a result of her worrying and the need to do something she enjoys.

Smoking is consistent with proposed anxiety, as it is a risk factor for dependence, which can cause a negative effect during abstinence with the expectation that smoking will reduce this effect between smoking and the prevalence of anxiety (Monroe et al, 2021).

Insomnia disorder due to other mental disorders meets the criteria for this client as she has difficulty maintaining sleep at night for greater than three months, and does not feel well rested. Older adults with chronic illnesses have difficulty falling asleep due to pain, cardiovascular disease, sleep apnea, or restless leg syndrome. Sleeping less than 5 hours or more than 10 hours nightly is associated with increased mortality.

Insomnia is more prevalent in older adults and is frequently linked to psychiatric and medical conditions. These individuals experience difficulty in concentrating and have a significant reduction in quality of life (Gulia & Kumar, 2018). (APA, 2013).

Reflections: I agree with my preceptor’s assessment and the client’s diagnosis based on the client’s presentation she appears just very depressed, but her irritability symptom changes the diagnosis to bipolar I disorder, depression episode, severe. I learned to always rule out a mood disorder, so as to not have a client go manic by just treating them for depression with an SSRI.

This case was somewhat challenging as the client had other circumstances that could contribute to her irritability, such as her pain, endocrine imbalance, as well as hormonal changes/imbalances. The treatment is appropriate because the patient has an effective pain medication regimen and the Latuda has improved the client’s mood giving her the neurotransmitters she is lacking.

Case Formulation and Treatment Plan: Obtain recent lab work from PCP or have the client’s blood drawn to assess any abnormal lab values that may be contributing factors to her diagnosis. Records from her physicians regarding her chronic pain and the interventions that led up to her pain. Surround treatment options to carefully enhance, but not interfere with another provider’s plan of care.

Communicate with other providers in the client’s care and collaborate on treatment options when appropriate. Provide opportunities for the client’s input related to the treatment plan. Instruct clients that they must continue to follow up with their PCPs as scheduled and as needed. Provide psychopharmacology education with printouts when possible.

Psychoeducation-related diagnosis, medications indications, side effects, and psychotherapy as part of the treatment. Communicate with the provider regarding OTC medications and if medications prescribed had any adverse or intolerable side effects, not to stop taking medications abruptly unless advised to do so by the provider.

Review current psychiatric medications with clients and have them recall the medications and their use as part of validating their knowledge of their mental illness. Emphasize the importance of psychotherapy as medications alone will not lead to successful outcomes. Instruct the client that there will be follow-up visits to assess progress and make changes when needed.

The clients will also have to have blood work monitored, in addition to weight, height, and vital signs with various psychotropic medications. In case of an emergency, the client is instructed to call the crisis hotline in their state, contact a friend, call 911, or go to the nearest emergency room.

References
American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th edition). American Psychiatric Association Publishing.
Gulia, K., Kumar, V. (2018). Sleep disorders in the elderly: a growing challenge. Psychogeriatrics 18, 155-165. https://doi.org/10.1111/psyg.12319.

Monroe, D., McDowell, C., Kenny, R., Herring, M. (2021). Dynamic associations between anxiety, depression, and tobacco use in older adults result from the Irish longitudinal study on aging. Journal of Psychiatric Research, 99-105. https://doi.org/10.1016/j.jpsychires.2021.05.017.

Rolin, D., Whelan, J., Montano, C. (2020). Is it depression or is it bipolar depression? Journal of the American Association of Nurse Practitioners 32, 703-713. https://doi.org/10.1097/JXX.0000000000000499.

Question no 1

what contributing factors affect patients who have psychiatric disorders and chronic medical disorders and diseases?

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Also check: NRNP 6675 WEEK 9 Response NO 2 to my colleague DEBORAH, M Grand Discussion post no 2