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NURS 6630 Case 11: The Figment of a Man Who Looked Upon a Lady
NURS 6630 Case 11: The Figment of a Man Who Looked Upon a Lady
In The Figment of a Man Who Looked Upon a Lady, the case involves a 42-year-old who presents with a chief complaint of interpersonal stress and depression. The assessment that followed revealed that the lady suffers from a comorbidity of MDD, PTSD, and SUD. The attending mental health practitioner plus other physicians collaborated to manage the mental health issues alongside medical conditions suffered by the patient. At the end, it was revealed that atypical antipsychotics could be utilized to manage all the comorbid conditions as they had all the anti-effects to them. In the present analysis, therefore, the nurse practitioner will assume the role of the attending physician and conduct a clinical interview with the patient alongside one of her physicians. In addition, based on pharmacokinetic and pharmacodynamics properties, the nurse practitioner will suggest two useful anti-depressants and utilize their mechanisms of action to decide the appropriate molecule for the patient.NURS 6630 Case 11: The Figment of a Man Who Looked Upon a Lady
Patient Clinical Interview Question
As mentioned in the introduction, the patient presents with chief complaints of stress and depression. Therefore, it will be paramount for the present nurse to diagnose the causes of these conditions and identify the comorbidities represented by the major symptomatology presented by the patient. To this end, the following questions will be administered to the patient according to the American Psychological Association (2013):
What would you classify as the most traumatic experience that you have ever had in your life?
During the past one month, have you ever had feelings of depression and hopelessness and have this ever bothered you?
How can you describe the pattern of your sleeping behavior?
The answers offered to those questions by the patient will reveal so much about her current condition. Given that the patient experiences stress and depression, the nurse suspects comorbidity in the patient. Thus, the questions will guide the nurse towards unravelling the exact comorbid conditions that may be accompanying the stress-induced PTSD in the patient.
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NURS 6630 Case 11: The Figment of a Man Who Looked Upon a Lady
NURS 6630 Case 11: The Figment of a Man Who Looked Upon a Lady
Clinical Interview Questions to People in the Patient’s Life
Considering that the patient is unmarried and does not have children, the only people that could be interviewed are one of her lecturers and her physician. These two at least have contact with the patient and they may know a few fundamental things regarding the patient’s condition. Thus, the physician will be tasked with answering the following question: “Which medications has the patient been using and for how long?” The question is important in many ways. However, the primary significance of the above question involves its ability to reveal the medical conditions that the patient has, which will help in the diagnostic process (First, 2015). The nurse practitioner will also ask the patient’s lecturer; “How does the patient react to social stressors while in class?” Again, the question will provide an insight into the patient’s response to social stressors in lieu of her effort to control her personality disorder (First, 2015). By doing this, the lecturer will help the nurse examine if the harrowing childhood experiences still have a bearing on the patient’s behavior.NURS 6630 Case 11: The Figment of a Man Who Looked Upon a Lady
Physical Examination and Diagnostic Tests
The patient asserts that her PTSD symptoms are more bothersome to her than the depression. Thus, the physical examination will look to examine if she has any underlying medical conditions that could be causing the PTSD symptoms (Irish et al., 2013). Given her medical history, the present nurse will order for a biomarker assessment of corticotrophin-releasing factor as well as alteration of brain structure will be important in the diagnosis of the condition. In addition to the above physicals, a psychological evaluation of the patient and the usage of the DSM-5 criteria will be important in the process. Further, blood and urine workouts will influence the process through elimination of medical conditions as causative agents of PTSD. Moreover, these diagnostic tests will influence the psycopharmacotherapy that the present nurse practitioner will create for the patient.NURS 6630 Case 11: The Figment of a Man Who Looked Upon a Lady
Differential Diagnoses for the Patient
The differential diagnosis of the PTSD is important because the conditions always presents with other disorders. In the present case, the diagnosis could be PTSD with depression or PTSD with substance abuse disorder. In addition, the patient could be diagnosed with PTSD, Major Depressive Disorder, and Substance Use Disorder. However, from the symptoms presented by the patient, she is suffering from PTSD with comorbid MDD and SUD. According to her health history, she struggles to stay sober by attending anonymous recovery groups while the present of PTSD automatically influences the existence of depression. Thus, the other two diagnosis are not comprehensive enough for the patient.
Pharmacologic Agents
The two pharmacological agents that will be considered for the antidepressant therapy for the patient include the following based on Stahl (2014):
Quetiapine (Seroquel) at a dosage of 50-300 mg/day.
Sertraline at a dosage of between 12.5-150 mg/day.
The decision to choose the two anti-depressants is affected by certain pharmacokinetic and pharmacokinetic factors. These two drugs have a relatively fast onset of action after administration (Stahl, 2014). In addition, they are not addictive and they are quickly eliminated from the system. Further, where’s they have a tolerability risk burden, careful administration cushions a patient against them.NURS 6630 Case 11: The Figment of a Man Who Looked Upon a Lady
However, while they may share a lot of those pharmacokinetic superiorities, their mechanism of action will hypothetically influence the decision of a health practitioner regarding which one to use. Quetiapine’s mechanism of action is believed to be modulated via an antagonist activity and serotonin and dopamine receptors (Stahl, 2013). The antagonistic influence on these receptors leads to increased concentration of catecholamine in the brain, hence improved mood for the patient. Sertraline also works by inhibiting the selective reuptake of serotonin by the neurons (Kamo et al., 2016). This increases the concentration of serotonin in the brain hence improved mood. Therefore, owing to the fact that quetiapine increases both dopamine and serotonin, this molecule will be preferred for the management of the depression symptomatology in the patient.
Effect of Ethnicity on Quetiapine’s Dosage and/or Contraindications
Limited studies have been conducted on the impact of ethnicity on the dosage and contraindications of quetiapine. However, a study on the effect of ethnicity on the dose-response relationship of atypical antipsychotics was conducted amongst Asian and Western populations. In this study, it was revealed that Asians showed more polymorphism in their CYP isoenzyme system. The existence of the genetic polymorphism in the Asian population makes them poor metabolizers of these drugs. As a result, Han and Pae (2013) postulated that tolerability issues were observed in the Asians when atypical antipsychotic dosages were increased. Therefore, this could be extrapolated to quetiapine as well although the results were inconclusive in this respect.
Checkpoint Changes
The data presented in the case study sees the nurse practitioner recommend certain changes to anti-depressants and even dosages. Given that the therapy is polypharmaceutical in nature, the present nurse will also consider using augmenting antipsychotics while removing certain anti-depressants from the therapy at appropriate points and times. However, there will be changes in dosages before such a decision is undertaken.
Lessons Learned
The case has made evident various lessons for the present health practitioner. One of the important lessons learned is that the successful management of the condition requires excellent interprofessional collaboration given the amount of issues that afflict the patient. Also, the nurse has learnt that sometimes using polypharmacy is the best option as applying SSRI and NDRI could lead to cancellation of side-effects in addition to offering clinical effectiveness. These two lessons are important as they will influence the nurse in future. For instance, the present health professional will look to create an important rapport with her other colleagues so as to smoothen things when faced with similar conditions. Moreover, while risky, the present health care practitioner will attempt to use atypical antipsychotics as the first line of therapy when dealing with such a convoluted situation. All in all, the lessons from the case have been important for the present health professional’s posterity.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. Arlington, VA: American Psychological Publishing.
First, M. B. (2015). Structured clinical interview for dsm-5 disorders – scid-5: Clinician version. Place of publication not identified: Amer Psychiatric.
Han, C. & Pae, C.U. (2013). Do We Need to Consider Ethno-cultural Variation in the Use of Atypical Antipsychotics for Asian Patients with Major Depressive Disorder? CNS Drugs, 27 (1), 47-51.
Irish, L. A., Gabert-Quillen, C. A., Ciesla, J. A., Pacella, M. L., Sledjeski, E. M., & Delahanty, D. L. (2013). An Examination of PTSD Symptoms as a Mediator of the Relationship between Trauma History Characteristics and Physical Health following a Motor Vehicle Accident. Depression and Anxiety, 30(5), 475–482. http://doi.org/10.1002/da.22034
Kamo, T., Maeda, M., Oe, M., Kato, H., Shigemura, J., Kuribayashi, K., & Hoshino, Y. (2016). Dosage, effectiveness, and safety of sertraline treatment for posttraumatic stress disorder in a Japanese clinical setting: a retrospective study. BMC Psychiatry, 16, 434. http://doi.org/10.1186/s12888-016-1138-5
Stahl, S. M. (2014). Essential psychopharmacology: The prescriber’s guide, 5th ed. Cambridge, NY: Cambridge Univ. Press.
Stahl, S.M. (2013).Stahl’s Essential Psychopharmacology, 4th ed. New York, NY: Cambridge University Press.