69yo Male pt: Suicidal, Insomnia, Anxiety, Headaches, Fatigue, Worthlessness - Essay Sample

Introduction

Patient's illness: a 69-year-old male patient who came in for follow up on his depression condition. The patient was previously on medication but has stopped taking the drug for some time now. The patient is suicidal and complains of Insomnia, restlessness, headaches, persistent anxiety, constant fatigue, irritable and feeling worthless. Patient denies abuse of alcohol or any other illicit drugs. The patient states that his first symptoms were persistent headaches, anxiety, and restlessness which he first noticed two years ago. He says that his pain and discomfort is mainly due to constant headaches and fatigue. The patient states that his symptoms have been worsening over the last three months but has drastically deteriorated in the previous month. The patient also indicates that his symptoms are often more pronounced when he alone or after taking foods high in sugar. Another associated sign stated by the patient is occasional chest pain.

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Course

Stressors

Collateral information: Patient's older sister has a history of depression and attempted suicides. Patient reports that he is physically inactive and rarely leaves home for a walk or any other physical exercise. The patient also states that he is often alone at home since everyone else goes for work

Staff observations: Patient is easily agitated, and portrays signs of sleep deprivation such as constant yawning, difficulty in concentration and forgetfulness. The patient is moderately cooperative.

Review of the system: cardiac; regular heart palpitations and rhythm. No impulses, murmurs or thrills noted. Respiratory; the throat is symmetrical in nature and chest

Walls expands and contracts. Patient's lungs are resonant with low pitched, hollow sounds. Normal breathing sounds, and breathing efforts noted. Dermatological; Patient's skin is warm to the touch and dry. Poor skin turgor is indicated. ENT; Patient's head is normacephalic with no physical injuries. Hair loss is noted. Eyes are healthy in colour and general appearance. Ears appear normal, and the ear canals are open. The nose is typical, with no abnormal discharge or nose bleeding. The neck is not stiff and moves smoothly. The trachea appears to be on the midline location. Thyroid glands appear healthy with no tenderness or inflammation. The throat seems to be healthy, with no lesions noted. The oral mucosa is normal with adequate moisture and pink colour. The tough appears normal, with no masses identified. Gastrointestinal; patient's abdomen is none distended and seems normal with no physical scars or swellings. No swelling is noted on the bladder; the stomach produces tympanic sounds upon percussions. Patient's chest region is asymmetrical. Both breasts are healthy in appearance with no swellings or skin abnormalities. Musculoskeletal; tenderness is noted on joints on the extremities. The patient has a score of 3/5 on muscle strength. Poor joint stability is indicated. Neurological; the patient is not alert and has a hard time answering questions. The sensory response of the patient is satisfactory.

Objective

Medications

Patient was on Zoloft 100mg daily, which was orally administered for seven months before he abruptly stopped the medication. Patient reports that he experienced mild drowsiness and dizziness while on Zoloft 100 mg. alongside the oral medication, the patient underwent seven psychotherapy sessions and one session of ECT procedure. PHQ 9; the results indicated that the patient indeed had a depression disorder where he marked that he had little interest or pleasure in doing things almost every day and that nearly every day, he suffers from the feeling of hopelessness and a general sense of being depressed. Mood questionnaire; results indicated that the patient had mood disorders where on several occasions, he felt that he was not his usual self on various aspects and that often, the multiple elements which he felt were not his usual-self occurred at the same time and caused him moderate trouble with his family and friends. Hamilton's questionnaire; results indicated that the patient had severe anxiety with an overall score of 25. Cage questionnaire; the patient scored 1, meaning that he didn't have a problem with alcoholism. AIMS examination; the patient scored 2, indicating that he experienced some form of involuntary movements.

• Vital signs: Temperature = 36.1, pulse rate = 66, weight = 76kgs, BM1 = 24.74, Height = 5.9".
• Appearance: moderately stable and normal gait and posture, well-groomed, clean and hygienic.
• General behaviour: well mannered, slow movement, mild cognitive impairment, decreased muscle movement and able to express himself.
• Attitude: Cooperative, secretive, easily distracted
• LOC: the patient is Lethargic and drowsy
• Attention: the patient has difficulty concentrating and is easily distracted
• Memory: patient's remote mind is excellent but has poor immediate and recent memories.
• Intellectual: the patient is well known.
• Speech: patient speaks in a soft tone, slow rate and in a paucity manner. The patient has a hesitant fluency while speaking.
• Mood: patient says he is depressed, anxious and irritable.
• Affect: the patient has a flat affect.
• Thought process: patient portrays a tangential thought process.
• Thought content: the patient is suicidal and feels hopeless.
• Insight/Judgment: very poor
• Lab review: normal CBC, normal TSH at 2.4, HbA1c is reasonable at 5.1

Assessment

The patient is male and is 69 years old who had previously been diagnosed with depression but ceased taking his medication after a while. Patient acknowledges he is depressed, irritable and is also suicidal. Although the patient has mood disorders, it is highly unlikely that the mood disorder could be caused by bipolar because the patient has never had episodes of manic or hypomanic. The patient appears to have depressive symptoms such as suicidal thoughts, irritability and sleep disorders, indicating the likelihood of major depressive disorder.

It is also unlikely that a patient's psychotic disorders could be as a result of substance abuse since the patient vehemently deny any use of substances. Patient's decreased muscle movement and slowness are likely due to his age. Most individuals over sixty-five years tend to lose their muscle movements slowly. The patient also indicates that his symptoms worsen when he is lonely and idle, which is a typical characteristic in patients with major depressive disorders. Given the patient's information available, the most likely diagnosis is a major depressive disorder (Otte et al. 2016).

DSM V

Axis 1- Mood disorders.

Axis 2- Deferred.

Axis 3- Muscle weakness, possibly age-related.

Axis 4- Severe loneliness and inability to work

Axis 5- Global assessment of function; 22 (Uher, Payne, Pavlova, & Perlis, 2014).

Plan

Mood disorder

Continue with Zoloft 100mg daily

Continue with ECT sessions for up to two or three times a week for a maximum of twelve sessions.

More lab examinations to include a head CT scan and ECG.

Gather more information from previous hospital visits and family members.

A discussion was held with the patient to explain the possible side effects of the medication prescribed. Such side effects include metabolic changes, seizures, blurred vision, and insomnia, among other side effects. Patient acknowledges that he fully understood the side effects.

Disposition

The patient is put under a 72 hours Involuntary Treatment Act (ITA)

References

Otte, C., Gold, S. M., Penninx, B. W., Pariante, C. M., Etkin, A., Fava, M. & Schatzberg, A. F. (2016). Major depressive disorder. Nature Reviews Disease Primers, 2, 16065.

Uher, R., Payne, J. L., Pavlova, B., & Perlis, R. H. (2014). Major depressive disorder in DSM 5: Implications for clinical practice and research of changes from DSM IV. Depression and anxiety, 31(6), 459-471.