Psychiatric Case Study
Annual examination; fatigue
Angela is a 54-year-old married woman with three adult children. She has been the office manager of a small law firm for 20 years and has enjoyed her work until this past year.
She has been taking conjugated estrogens for 8 years and decided to stop taking them because of her concern of their risks without sufficient medical benefit. She has tolerated the discontinuation without difficulty.
At her annual medical checkup appointment, she told her primary care provider that she seemed to be tired all of the time, and she was gaining weight because she had no interest in her usual exercise activities and had been overeating, not from appetite but
out of boredom. She denied that she and her husband have had marital difficulties beyond the ordinary and she was pleased with the achievements of her children. She noticed that she has difficulty falling asleep at night and awakens around 4 a.m. most mornings without her alarm and cannot go back to sleep even though she still feels tired. She finds little joy in her life but cannot pinpoint any particular concern. Although she denies suicidal feelings, she does not feel that there is meaning to her life:
“My husband and kids would go on fine if I died and probably would not
miss me that much.”
The primary care provider asks Angela to fill out a Beck’s Depression Scale, which
indicated that she has moderate depression.
Physical Exam is unremarkable.
CBC, CMP, TSH, all within normal range.
Assessment: Moderate Depression
What is the treatment plan for Angela today?: Must use evidence based reference with citations on all questions
- Pharmacologic? This should include any OTC medications
- Use blank prescription document to write prescriptions for your pharmacologic treatments.
- Non pharmacologic? This should also include any patient education
- Follow up and Referral?
No more than 2 pages for treatment plan
Cite any lab/diagnostic testing needed for before prescribing that are required and any needed for monitoring. State MOA of drug/drug class, ADME of each medication (short summation of 1 or 2 sentences), patient education/counseling or side effect education that should be included. Note pertinent drug-drug interactions (do not list every drug interaction. Can state CYP450 inhibitor etc. Or if the patient is already taking a medication that could be an issue), Black Box warnings and life span considerations? No more than 1-2 pages for med info
Please provide rationale and reference.
Use a title page and Reference Page
See attached Rubric for grading
- Pharmacologic? This should include any OTC medications
Informatics Interactive Case Study
Angela is a 54-year-old married woman with three adult children who comes to the clinic for her medical checkup. She told her primary care provider that she seemed to be tired all of the time, and she was gaining weight because she had no interest in her usual exercise activities and had been overeating, not from appetite but out of boredom.
Plan: antidepressants and psychotherapy.
Pharmacologic: Lexapro (Escitalopram)
Escitalopram is used to treat and manage anxiety and depression. Escitalopram belongs to selective serotonin reuptake inhibitors (SSRIs) drugs which are used to treat depression and anxiety. The drugs block the absorption or reuptake of serotonin in the brain (Duman, 2015). They are known as “selective” since they majorly affect serotonin and not any other neurotransmitters in the brain. The drug essentially improves appetite, mood, sleep, and energy level which then reestablish patient back to have interest in daily activities.
Psychotherapy: Cognitive Behavioral Therapy (CBT)
Regular exercise assists to create improve mood and positive feeling.
Counseling in order to reduce the stressful thoughts
Being in a company of people most of the times in order stop loneliness which creates room for negative thoughts.
Prevention: Depression can be genetically acquired hence, in some instances, it is difficult to prevent it. However, it is important to avoid risk factors that are associated with the condition which include bad thoughts which bring about sadness (Duman, 2015). In order to have good moods it is vital to have regular exercise which assists to create positive feelings and improve moods. It is also essential to avoid lonely occasions which create room for negative thought hence stress and finally depression.
Diagnostics: Physical Examination Using the Symptoms
Follow Up: It depends with the persistency of the symptoms that were initially experienced. Some of the symptoms which may prompt follow up include mood change, inability to sleep, lack of interest in daily activities, and fatigue (Bennett & Thomas, 2014). When these symptoms do not reduce after intervention, it is important to visit the doctor to advice on the way forward. In a case where there the symptoms are not reducing, the doctor can stop the drug or increase its dosage.
Referral: No referrals is needed at this time
Mechanism: Lexapro (Escitalopram) acts as a potent serotonin reuptake inhibitor with an affinity for serotonin. By hindering the reuptake of serotonin into presynaptic neuron, it upturns extracellular echelons of serotonin and thus upsurges serotonergic neurotransmission within the brain (). It is this process that is believed to be responsible for the antidepressant effects of sertraline.
Absorption: Following oral administration, escitalopram is promptly absorbed and reaches maximum plasma concentrations in about 3-4 hours after either in single- or multiple-dose administration.
Distribution: The drug is absorbed by achieving its maximum convention then it is distributed to the whole body. In vitro studies assert that it is more than 98% protein-bound.
Metabolism: Metabolism is hepatic; the drug goes through momentous first-pass metabolism. Escitalopram experiences N-demethylation to S-demethylcitalopram (S-DCT) and S-didemethylcitalopram (S-DDCT). CYP3A4 and CYP2C19 are the enzymes responsible for the N-demethylation reaction.
Excretion: It is excreted generally as metabolites in feces and urine. Average removal half-life is 25 hours. Stable state stages are attained within a week of everyday dosage in young patients.
Side effects: headache, dizziness, insomnia, tremor, paresthesia, hypoesthesia somnolence, fatigue, hypertonia.
Interaction: Citalopram, same as other SSRIs (with only fluvoxamine as exception), prevents CYP2D6 and which increases the level of plasma of several CYP2D6 substrates such as risperidone, aripiprazole, codeine, and tramadol.
Black Box Warning: no
Bennett, S., & Thomas, A. J. (2014). Depression and dementia: cause, consequence or coincidence?. Maturitas, 79(2), 184-190.
Duman, R. S. (2015). Spine synapse remodeling in the pathophysiology and treatment of depression. Neuroscience letters, 601, 20-29.
Fried, E. I., & Nesse, R. M. (2015). Depression sum-scores don’t add up: why analyzing specific depression symptoms is essential. BMC medicine, 13(1), 72.
Izgi, C., Erdem, G., Mansuroglu, D., Kurtoglu, N., Kara, M., & Gunesdogdu, F. (2014). Severe hypokalemia probably associated with sertraline use. Annals of Pharmacotherapy, 48(2), 297-300.
Kendall-Tackett, K. A. (2016). Depression in new mothers: Causes, consequences and treatment alternatives. Routledge.