Posted: August 2nd, 2022

Grand Rounds Discussion: Complex Case Study Presentation Questions.

Objectives

1.Demonstrate adequate understanding of the common symptoms of major depression and PTSD.

2. Demonstrate a high level of knowledge on the underlying causes of posttraumatic stress disorder and suicide based on trauma, family issues, and life stressors.

3. Develop knowledge on mental status examination and prioritization of treatments for mental illness based on psychotherapy and pharmacology.

4. Demonstrate understanding of the possible lifestyle changes to improve physical and psychological outcomes among adults.

Subjective:

CC (chief complaint): “Suicidal thought to shoot himself in the head and frequent nightmares”

HPI: N.R is a 56-year-old male of African American origin who presented to the mental health facility with significant suicidal thoughts and nightmares. The police arrested him after he threatened to shoot himself in the head in front of his neighbor. N.R was placed on emergency hold by the police in response to the self-harm threat. He is a military veteran with seven years in Afghanistan. He has been unable to manage his grocery store due to suicidal thoughts experienced for the last four months. The patient told his neighbor, “I am going to shoot my head to remove demons that live inside.” The patient reported that he has been experiencing nightmares and hearing voices from his comrades who died in a raid during deployment. He has been planning to die by the bullet so that all his problems would come to an end. The patient reported that he has been unable to sleep for more than four hours at night. He prefers to sleep during daytime and feels tired most of the time. He reports feeling depressed most of the time for the last four months. He separated from his wife after ten years of marriage due to frequent physical violence. His patient records shared by psychiatrists show that he was treated for major depressive disorder two years ago. He reports that he has been unable to eat well due to poor appetite. The patient reports flashbacks related to his experience in the raid that resulted in the death of his best friend in the military. He has been trying to avoid discussions related to war or military action due to the negative memories. He experiences decreased interest in playing his favorite game with friends. He reports that he is always ready to shoot his enemies who are planning to attack at night. The patient reports that his family is not supportive and is happy about his current situation. The patient is aggressive and easily irritated during interactions. The patient reports feeling sad and having difficulty concentrating in the workplace.

Substance Current Use: Patient reports that he smokes two packets of cigarette every day. He reports occasional intake of alcohol at least once week when free. He denies illegal drug use or marijuana use. He was prescribed with morphine for pain management five years ago but did not develop dependence.

Past Psychiatric History: Patient was diagnosed with major depressive disorder 2 years ago and treated using medication. He has history of substance abuse disorder which was treated six years ago. He reports that he cannot remember his experience as a child related to trauma. He suffered trauma during military deployment in service.

Medical History: Has history of hypertension which is managed using medication and lifestyle change.

· Current Medications: Lisinopril 10 mg once daily for HTN and Prozac 20 mg once daily for depression.

· Allergies: Iodine.

· Reproductive Hx: Patient is heterosexual. He engages in sexual relationships with multiple women after divorce from his wife. He reports that he uses condoms for protecting against STI. He is unable to seek screening for prostate related problems due to the current mental illness.

Psychotherapy: Patient received cognitive behavioral therapy two years ago for depression.

Family Medical History: Father 76 years-old with history of diabetes mellitus and HTN. Mother 74 years with history of hypertension and hyperlipidemia. Younger brother, no known medical history.

Social History: Patient lives alone in a three-bedroom house in a middle-income neighborhood. He separated from his wife due to his behavior and aggression that resulted in physical violence. He is a father of two three children son 20, daughters 12, and 15. He is allowed to visit his children at least once every week after divorce. He pays child support for the children. He reports that his family is not supportive and feels isolated. He has been unable to go out with friends due to the psychological change. He reports that he is always aware of people planning to eliminate him during social events. He has been working at his grocery store with three other employees. He reports that the pandemic contributed to his current problems because he secured a bank loan to support his business. He reports smoking at least two packets every day. He reports alcohol intake occasionally once per week. Patient denies illegal drug use or marijuana. He has travelled to Europe, west Africa, and Middle East during military missions.

Family Psychiatric History: Father has history of major depressive disorder and suicidal thoughts. Mother has history of anxiety and bipolar II disorder.

ROS:

· GENERAL: Pt is well-groomed. Alert and oriented x4. Reports weakness and fatigue for the past four months. No chills, fever. Reports weight loss of 10 pounds in the last five months.

· HEENT: Head: Normocephalic and symmetric to the body. TJM full ROM. Maxillary sinuses no tenderness. Eyes: Symmetrical, sclera white, conjunctiva pink. Eye movement intact. No hemorrhages, lens opacities or disk cupping. Ears: External ear no masses, tenderness or injuries. Nose: Nasal mucous moist and free from bleeding. Throat: Pink and most membranes. No difficulties swallowing or swelling.

· SKIN: Color appropriate to race. No lesions, rashes, or ulcers.

· CARDIOVASCULAR: Denies chest pain, heart murmur or edema. No cubbing or cyanosis.

· RESPIRATORY: No abnormal breathing sounds difficulties breathing. No wheezing or use of accessory muscles. No cough or sputum.

· GASTROINTESTINAL: Denies constipation, diarrhea, abdominal pain, or nausea. No blood in stool or swelling.

· GENITOURINARY: Denies frequent urination, blood in urine, swelling or difficulties starting urination.

· NEUROLOGICAL: Denies confusion, dizziness, or headache. Tongue protrudes midline.

· MUSCULOSKELETAL: Denies problems with ROM or pain in joints or muscle.

· HEMATOLOGIC: Denies bleeding, bruising or recent blood transfusion.

· LYMPHATICS: No swelling or tender lymph nodes noted or reported.

· ENDOCRINOLOGIC: Denies cold or heat intolerance.

· PSYCHIATRIC: Reports depressed mood, sadness, nightmares, and fatigue.

Objective:

General Appearance: 56-year-old male. Well-groom and oriented x4.

Diagnostic results:

Vital Signs & Measurements:

T 98.2, P 92, R 18, B/P 118/85, O2SATS 99% RA, WT 120 lbs, HGT 5’9”, BMI 18.5

· CBC, CMP, TSH, VITAMIN D LEVELS, UDS,-WNL

· A1C; 5.2%

· SARS COVID 19 PCR; -Not Detected

· EKG; -WNL

· Platelet: WNL

Assessment:

Mental Status Examination:

N.R is a 56-year-old male who appears well groomed and oriented in place, time, person and situation. Appearance of appropriate for his age. His behavior is cooperative. He maintains appropriate eye contact. Has pressured and fast speech. No abnormal involuntary movements noted during assessment. He has poor control of his mood and irritability during interaction. His affect is labile and flat. His mood is sad, angry, and despondent. Thought process is distorted and rambling. He denies hallucinations and delusions. Patient has impaired insight evidenced by difficulties evaluating his problems and poor judgment based on suicidal ideation. Has appropriate attention based on adherence to instructions during the last 10 minutes of assessment. Concentration is poor as evidenced during assessment. His immediate, recent, and remote memory is fair. The patient can recall recent events and previous experiences. Patient has poor impulse control. Patient is actively suicidal and at risk of harm to self. Patient has fair intellectual capacity and fund of knowledge as demonstrated during interpretation of previous diagnosis and education.

Diagnostic Impression:

1. Posttraumatic Stress Disorder (PTSD) F43.1): The patient meets the criteria for PTSD due to exposure to trauma in military, avoidance, hypervigilance, irritability, and depressed mood (Pai et al., 2017). Posttraumatic stress disorder is associated with depressed mood and fatigue that represent the underlying depression. The patient reports nightmares, intrusions, and sleep problems.

2. Major depressive disorder recurrent without psychotic symptoms F33.9; Patient reports symptoms related to depressive disorder including depressed mood most of the time for the past four months, poor sleep, difficulties concentrating, fatigue, reduced appetite, and suicidal ideation (Tolentino & Schmidt, 2018). The depressive disorder can occur with PTSD due to history of trauma. The patient has history of depression which supports the diagnosis.

3. Generalized Anxiety Disorder F41.1: The diagnosis based on the reported anxiety and worries due to enemies planning to eliminate the patient. He reports increased fear, difficulties concentrating and irritability (Patriquin & Mathew, 2017). The patient reports fear of public places that prevents his interaction with friends.

Case Formulation and Treatment Plan:

The patient is suicidal and has poor emotional control related to trauma and depression. He has been contemplating shooting himself in the head due to nightmares and current problems. The active trigger is flashbacks about the raid during deployment. The patient will be admitted to the mental healthcare facility based on the diagnostic outcomes. The first intervention for the patient is selective serotine reuptake inhibitor sertraline with an initial dose of 50 mg once a day followed by an increase to 75 mg once daily (Nguyen & Moussa, 2022). The patient will receive Prozac 25 mg once daily for four weeks to improve symptoms of PTSD and depression. The second treatment for the patient is cognitive behavioral therapy in a group thrice a week during hospitalization and after discharge. Cognitive behavioral therapy is effective in managing irritational thoughts in patients with PTSD and depression (Watkins et al., 2018). The psychiatrist will recommend the police seek a court order to have the patient surrender his firearm to the local police during treatment. A psychiatric evaluation will be performed after five days to determine improvements. The patient will be discharged to go home and assigned to a community mental healthcare professional to monitor his adherence to treatment and changes for treatment. The patient is assigned a family support program to enhance social support after discharge.

Lifestyle Education:

The patient reports smoking which requires proper support and education to reduce negative outcomes. The patient is provided with information about the negative health effects of smoking and the available smoking cessation programs in the community. The patient will receive a text message notification for smoking cessation to enhance lifestyle change. The integration of technology is important for smoking cessation in an outpatient setting. The patient is also educated to increase the intake of fruits and vegetables and to follow the medication guidelines. 

Reflections:

The patient’s case provided an important opportunity to evaluate a complex mental disorder. Major depressive disorder and PTSD can co-occur in patients resulting in negative outcomes. The risk of suicide and treatment guidelines was important for the patient to prevent harm (Fox et al., 2021). Patient assessment to capture the history and the current triggers were important for the diagnosis and treatment plan. The recommended treatment, Sertraline, and Prozac are important to reduce the risk of overdose. Patients are less likely to report negative side effects related to SSRIs, improving safety outcomes (Nguyen & Moussa, 2022). A continuous dose adjustment and risk monitoring will be initiated for the patient to achieve the treatment goals. The patient will receive support and psychotherapy to develop coping skills. Proper coordination with the community mental healthcare providers and support programs for smoking cessation is also important for the patient to address the current physical and psychological issues.

References

Fox, V., Dalman, C., Dal, H., Hollander, A., Kirkbride, J. B., & Pitman, A. (2021). Suicide risk in people with post-traumatic stress disorder: A cohort study of 3.1 million people in Sweden. Journal of Affective Disorders, 279, 609-616. 

https://doi.org/10.1016/j.jad.2020.10.009

Nguyen, M., & Moussa, M. (2022). Suicidal ideation with vague and contradicting history. Psychiatric Emergencies, 157-164. 

https://doi.org/10.1093/med/9780197544464.003.0023

Pai, A., Suris, A., & North, C. (2017). Posttraumatic stress disorder in the DSM-5: Controversy, change, and conceptual considerations. Behavioral Sciences, 7(4), 7. 

https://doi.org/10.3390/bs7010007

Patriquin, M. A., & Mathew, S. J. (2017). The neurobiological mechanisms of generalized anxiety disorder and chronic stress. Chronic Stress, 1, 247054701770399. 

https://doi.org/10.1177/2470547017703993

Tolentino, J. C., & Schmidt, S. L. (2018). DSM-5 criteria and depression severity: Implications for clinical practice. Frontiers in Psychiatry, 9. 

https://doi.org/10.3389/fpsyt.2018.00450

Watkins, L. E., Sprang, K. R., & Rothbaum, B. O. (2018). Treating PTSD: A review of evidence-based psychotherapy interventions. Frontiers in Behavioral Neuroscience, 12. 

https://doi.org/10.3389/fnbeh.2018.00258

PLEASE READ ABOVE ASSIGNMENT PAPER, AND

ANSWER TWO QUESTIONS OUT OF 3 BELOW WITH ATLEAST 2 REFERENCES. THANK YOU VERY MUCH.

Questions

1). The patient has a history of major depressive disorder. Do you think the recommended treatment is effective in managing depression and PTSD? What are your adjustments to achieve treatment goals for the patient?

2. The patient will receive cognitive behavioral therapy as the main non-pharmacologic intervention; what other intervention is most applicable for the patient based on the diagnostic data?

3. The patient reports that his family does not provide support. Would the patient benefit from group therapy? What other community support programs are available for veterans with PTSD?

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