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Presentation/PPT
27/08/2022
Examine Case Study: An Elderly Hispanic Man With Major Depressive Disorder. You will be asked to make three decisions concerning the medication to prescribe to this client. Be sure to consider factors that might impact the client’s pharmacokinetic and pharmacodynamic processes.
BACKGROUND INFORMATION
The client is a 32-year-old Hispanic American male who came to the United States when he was in high school with his father. His mother died back in Mexico when he was in school. He presents today to the PMHNPs office for an initial appointment for complaints of depression. The client was referred by his PCP after “routine” medical work-up to rule out an organic basis for his depression. He has no other health issues with the exception of some occasional back pain and “stiff” shoulders which he attributes to his current work as a laborer in a warehouse.
SUBJECTIVE
During today’s clinical interview, client reports that he always felt like an outsider as he was “teased” a lot for being “black” in high school. States that he had few friends, and basically kept to himself. He describes his home life as “good.” Stating “Dad did what he could for us, there were 8 of us.” He also reports a remarkably diminished interest in engaging in usual activities, states that he has gained 15 pounds in the last 2 months. He is also troubled with insomnia which began about 6 months ago, but have been progressively getting worse. He does report poor concentration which he reports is getting in “trouble” at work.
MENTAL STATUS EXAM
The client is alert, oriented to person, place, time, and event. He is casually dressed. Speech is clear, but soft. He does not readily make eye contact, but when he does, it is only for a few moments. He is endorsing feelings of depression. Affect is somewhat constricted, but improves as the clinical interview progresses. He denies visual or auditory hallucinations, no overt delusional or paranoid thought processes readily apparent. Judgment and insight appear grossly intact. He is currently denying suicidal or homicidal ideation. The PMHNP administers the “Montgomery- Asberg Depression Rating Scale (MADRS)” and obtained a score of 51 (indicating severe depression).
RESOURCES
§ Montgomery, S. A., & Asberg, M. (1979). A new depression scale designed to be sensitive to change. British Journal of Psychiatry, 134, 382-389.
Decision Point One
Begin zoloft 25 mg orally daily
Begin Effexor XR 37.5 mg orally daily
Begin Phenelzine 15 mg orally TID
Decision Point One
Begin zoloft 25 mg orally daily
RESULTS OF DECISION POINT ONE
Decision Point Two
Decrease dose to 12.5 mg orally daily
Continue same dose and counsel client
Add augmenting agent such as Wellbutrin IR 150 mg in morning
Decision Point Two
Add augmenting agent such as Wellbutrin IR 150 mg in morning
RESULTS OF DECISION POINT TWO
Decision Point Three
Discontinue Zoloft altogether and continue with Wellbutrin
Change Wellbutrin to XL 150 mg orally daily in AM
Add Ativan 0.5 mg orally TID/PRN for anxiety
Decision Point Three
Change Wellbutrin to XL 150 mg orally daily in AM
Guidance to Student
The PMHNP should be aware that Zoloft or Wellbutrin could be responsible for the client complaints of Jitteriness. This feeling is usually temporary with SSRIs, however. The cause of the client’s complaint of “jitteriness” is most likely related to the Wellbutrin immediate release. As a result, the most appropriate answer would be to change the Wellbutrin to an extended release formulation. It would not be appropriate to add Ativan as the PMHNP should never add an additional medication to treat the side effect of another medication without first attempting to modify/change the medication causing the side effect.
The writer is very fast, professional and responded to the review request fast also. Thank you.
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