Depression And Anxiety Case Study

Discontinuing Antidepressant due to Side Effects in 59-Year-Old

The Issue: Managing side effects so a patient with good response will remain adherent to the treatment plan.

Patient History

The patient is a 49-year-old married woman with three grown children.

She is moderately overweight (BMI 31) and was diagnosed with non-insulin-dependent diabetes 10 years ago; she is fairly well managed on an oral hypoglycemic medication (glipizide 10 mg twice per day). Three years ago, the patient experienced two tremendous stressors: her oldest child developed cancer (now in remission), and her mother passed away. She suffered a significant major depressive episode that went untreated until recently.

This was her sixth episode of depression; she experienced two major depressive episodes as a teenager, and she developed postpartum depression and anxiety following the births of each of her three children. Five months ago, after she was too fatigued to get out of bed, she sought treatment for the first time in her life.

After receiving education and support from her provider, she reluctantly agreed to take Paxil 30 mg/day.

The patient has experienced a near complete resolution of her symptoms in the last 7 months; however, she has developed unwanted side effects and wants to discontinue the medication. Specifically, she has increased appetite and has correspondingly gained 9 pounds in the last 5 months, with an increase in HgA1c of 1 full percentage point. She also reports excess daytime sedation and anorgasmia (very unusual for her).

1. What options can you offer to manage these side effects? Be specific.

2. What education should you give patients about stopping this medication abruptly?

3. What is your treatment plan moving forward?

Complete a full intake on this patient and then develop a treatment plan using the  case study template  offered.

Student work demonstrates an attempt to appraise use of evidence-based best practices related to pharmacological, non-pharmacological, and complementary therapeutic treatment plans for individuals with acute, chronic, and complex, mental health disorders. The content was thorough, relevant to the topic, and illustrated critical analysis.

MN660 Case Study Psychiatric SOAP Note and Rx Template

 

Use this SOAP Note and Rx template to complete the Case Study. There are different ways in which to complete a Psychiatric SOAP (Subjective, Objective, Assessment, and Plan) Note. This is a template that is meant to guide you as you continue to develop your style of SOAP in the psychiatric practice setting.

 

Criteria Clinical Notes
Subjective  
Include chief complaint, subjective information from the patient, names and relations of others present in the interview, and basic demographic information of the patient. HPI, Past Medical and Psychiatric History, Social History, Review of Systems (ROS) – if ROS is negative, “ROS noncontributory,” or “ROS negative with the exception of…”.  
Objective

This is where the “facts” are located. Include relevant labs, test results, vitals, and physical exam if performed. Include MSE, risk assessment here, and psychiatric screening measure results.  
Assessment  
Include your findings, diagnosis and differentials (DSM-5 and any other medical diagnosis) along with ICD-10 codes, treatment options, and patient input regarding treatment options (if possible), including obstacles to treatment.  
Plan  

 

 

 

Include a specific plan, including medications & dosing & titration considerations, lab work ordered, referrals to psychiatric and medical providers, therapy recommendations, holistic options and complimentary therapies, and rationale for your decisions. Include when you will want to see the patient next. This comprehensive plan should relate directly to your Assessment.  

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PRESCRIPTION (for student use-Not VALID)

 

 

Purdue Global Medical Clinic

15 Medical Clinic Circle

Destination, SS, 00123

Phone: 123 456 7890

Fax: 123 456 7890

 

 

PMHNP Student Jane Purdue, APRN

License # SS 17245A

NPI # 1234567899

 

 

 

 

PATIENT DETAILS: DATE:

 

NAME

………………Patient Doe……………………………………………………………..…..

 

DOB …….………………………………………………………..

 

ADDRESS

……………3515 Admiral Way……………………………………………………………

 

…………….Destination, SS 00123……………………………………………………..

A picture containing text  Description automatically generated

 

 

 

 

 

 

 

 

 

 

___________________

Prescriber’s signature

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Copy any Case study questions from the instructions and answer here.

 

 

 

 

NW_10/17/20