PRAC 6675 WEEK 4 COMPLEX CASE STUDY PRESENTATION PEER RESPONSES

Complex Case Study Peer Response
Hello Chin. Thank you so much for your insightful case presentation. I agree with you that recurrent major depressive disorder is CR’s primary diagnosis. Your diagnosis meets the DSM criteria for major depressive disorder. According to DSM-5, patients are diagnosed with major depressive disorder if they show symptoms of a depressed mood every day almost throughout the day. Patients must also report a lack of interest or pleasure, feelings of guilt or hopelessness, fatigue, changes in sleep patterns and appetite, and difficulty concentrating. Patients also report sleep problems, difficulty making decisions, and suicidal thoughts, plans, or attempts. The symptoms cause impaired social, occupational, and functioning in other areas of a patient’s life. The symptoms should not be attributed to other causes such as medication use, medical conditions, or psychiatric problems (Guidi & Fava, 2021; Trivedi, 2020). CR’s symptoms meet the above criteria. For example, CR reports that she has been experiencing frequent depressive episodes almost daily, is disinterested in work or play, has hypersomnia, feels worthless, and is inattentive.
Indeed, post-traumatic stress disorder, with delayed expression is one of the differential diagnoses that should be considered for CR. Post-traumatic stress disorder is a mood disorder that develops in individuals with direct or indirect traumatic experiences. According to DSM-5, patients’ symptoms should meet the developed criteria for them to be diagnosed with post-traumatic stress disorder. They include a direct or indirect experience of traumatic events, the presence of intrusion symptoms such as distressing dreams, thoughts, and flashbacks about the trauma, and avoidance of stimuli that relate to the traumatic event. Patients should also demonstrate negative alterations in mood and cognitions associated with the trauma and changes in reactivity and arousal related to the traumatic event (Maercker et al., 2022). The case study reveals that CR has a history of sexual abuse. However, the absence of the above symptoms associated with post-traumatic stress disorder rules it out as a primary diagnosis.

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References
Guidi, J., & Fava, G. A. (2021). Sequential Combination of Pharmacotherapy and Psychotherapy in Major Depressive Disorder: A Systematic Review and Meta-analysis. JAMA Psychiatry, 78(3), 261–269. https://doi.org/10.1001/jamapsychiatry.2020.3650
Maercker, A., Cloitre, M., Bachem, R., Schlumpf, Y. R., Khoury, B., Hitchcock, C., & Bohus, M. (2022). Complex post-traumatic stress disorder. The Lancet, 400(10345), 60–72. https://doi.org/10.1016/S0140-6736(22)00821-2
Trivedi, M. H. (2020). Major Depressive Disorder in Primary Care: Strategies for Identification. The Journal of Clinical Psychiatry, 81(2), UT17042BR1C. https://doi.org/10.4088/jcp.ut17042br1c

Response 2
Hello Chin. Thank you so much for your insightful presentation. Indeed, depressive disorder due to other medical conditions should be considered in CR’s case. The case shows that CR has a history of hypothyroidism. Patients with hypothyroidism experience symptoms of a depressed mood, as seen in major depression. However, thyroid function tests would rule out hypothyroidism as the cause of CR’s depression if the thyroid hormone levels were normal (Nuguru et al., 2022). Besides, the PHQ score confirms a diagnosis of severe depression, hence, making depression due to other medical conditions the least likely cause of CR’s problems.
I agree with the treatment decisions you made for CR. Antidepressants are the first-line drugs of choice for patients diagnosed with major depression. Stopping antidepressants would lead to worsening symptoms and CR’s poor quality of life. I believe that it would have been appropriate to stop Wellbutrin and amitriptyline and start CR on oral sertraline 50 mg once daily. Selective serotonin reuptake inhibitors have high safety and efficacy levels compared to amitriptyline and Wellbutrin (Jakobsen et al., 2020). Thyroid function tests should be performed to rule out abnormal thyroid hormone levels in CR’s case. CR should also be prescribed appropriate treatments based on thyroid function test results.
It would also be appropriate to start CR on psychotherapy. Treatments such as cognitive behavioral therapy would transform CR’s thoughts and behaviors. Combining pharmacotherapy and non-pharmacological interventions in major depressive disorder improves outcomes and prevents symptom relapse. The case study shows that CR is a smoker. Smoking affects the pharmacotherapy and pharmacodynamics of different drugs (Guidi & Fava, 2021). Therefore, she should be counseled on smoking cessation. CR’s follow-up is appropriate since antidepressants take between two and six weeks to produce the desired outcomes in major depression treatment.

References
Guidi, J., & Fava, G. A. (2021). Sequential Combination of Pharmacotherapy and Psychotherapy in Major Depressive Disorder: A Systematic Review and Meta-analysis. JAMA Psychiatry, 78(3), 261–269. https://doi.org/10.1001/jamapsychiatry.2020.3650
Jakobsen, J. C., Gluud, C., & Kirsch, I. (2020). Should antidepressants be used for major depressive disorder? BMJ Evidence-Based Medicine, 25(4), 130–130. https://doi.org/10.1136/bmjebm-2019-111238
Nuguru, S. P., Rachakonda, S., Sripathi, S., Khan, M. I., Patel, N., & Meda, R. T. (2022). Hypothyroidism and Depression: A Narrative Review. Cureus. https://doi.org/10.7759/cureus.28201

COMPLEX CASE STUDY PRESENTATION

In Weeks 4, 7, and 9 of the course, you will participate in clinical discussions called grand rounds. In one of these three weeks, you will be a presenter as well as help facilitate the online discussion; in the others you will be an active discussion participant. When it is your week to present, you will create a Focused SOAP note and a short didactic (teaching) video presenting a real (but de-identified) complex patient case from your practicum experience.

You should have received an assignment from your Instructor letting you know which week of the course you are assigned to present.

RESOURCES

Be sure to review the Learning Resources before completing this activity.

Click the weekly resources link to access the resources.

WEEKLY RESOURCES

LEARNING RESOURCES

Required Readings

Carlat, D. J. (2017). The psychiatric interview (4th ed.). Wolters Kluwer.

Chapter 26, “Assessing Alcohol Use Disorder”

MeditrekLinks to an external site.

https://edu.meditrek.com/Default.html

Note:?Use this website to log into?Meditrek?to report your clinical hours and patient?encounters.to an external site.

Document: Focused SOAP Note Template (Word document)Download Focused SOAP Note Template (Word document)

Document: Focused SOAP Note Exemplar (Word document)Download Focused SOAP Note Exemplar (Word document)

Stern, T. A., Fava, M., Wilens, T. E., & Rosenbaum, J. F. (2016). Massachusetts General Hospital psychopharmacology and neurotherapeutics. Elsevier.

Chapter 15, “Alcohol-Related Disorders”

Chapter 16, “Drug Addiction”

Office of Disease Prevention and Health Promotion. (n.d.). Social Determinates of Health.Links to an external site. Healthy People 2030. U.S. Department of Health and Human Services. https://health.gov/healthypeople/priority-areas/social-determinants-health

Recommended Readings

American Psychiatric Association. (2018). Practice guideline for the pharmacological treatment of patients with alcohol use disorderLinks to an external site.. https://psychiatryonline.org/doi/book/10.1176/appi.books.9781615371969

Links to an external site.

American Society of Addiction Medicine. (2020). Clinical practice guidelines on alcohol withdrawal managementLinks to an external site.. https://www.asam.org/docs/default-source/quality-science/the_asam_clinical_practice_guideline_on_alcohol-1.pdf?sfvrsn=ba255c2_2

Links to an external site.

American Society of Addiction Medicine. (2020). National practice guideline for the treatment of opioid use disorder: 2020 focused updateLinks to an external site.. http://eguideline.guidelinecentral.com/i/1224390-national-practice-guideline-for-the-treatment-of-opioid-use-disorder-2020-update/0Links to an external site.

Boland, R. Verdiun, M. L. & Ruiz, P. (2022). Kaplan & Sadock’s synopsis of psychiatry (12th ed.). Wolters Kluwer.

TO PREPARE:

Review this week’s Learning Resources and consider the insights they provide. Also review the Kaltura Media Uploader resource in the left-hand navigation of the classroom for help creating your self-recorded Kaltura video.

Select a child/adolescent or adult patient from your clinical experience that presents with a significant concern. Create a focused SOAP note for this patient using the template in the Resources. All SOAP notes must be signed by your Preceptor. When you submit your SOAP note, you should include the complete SOAP note as a Word document and PDF/images of completed assignment signed by your Preceptor. You must submit your SOAP Note using Turnitin.

Please Note: Electronic signatures are not accepted. If both files are not received by the due date, Faculty will deduct points per the Walden Late Policies.

Then, based on your SOAP note of this patient, develop a video case study presentation. Take time to practice what you will say beforehand, and ensure that you have the appropriate lighting and equipment to record the presentation.

Your presentation should include objectives for your audience, at least 3 possible discussion questions/prompts for your classmates to respond to, and at least 5 scholarly resources to support your diagnostic reasoning and treatment plan.

Video assignment for this week’s presenters:

Record yourself presenting the complex case study for your clinical patient. In your presentation:

Dress professionally and present yourself in a professional manner.

Display your photo ID at the start of the video when you introduce yourself.

Ensure that you do not include any information that violates the principles of HIPAA (i.e., don’t use the patient’s name or any other identifying information).

State 3–4 objectives for the presentation that are targeted, clear, use appropriate verbs from Bloom’s taxonomy, and address what the audience will know or be able to do after viewing.

Present the full complex case study. Include chief complaint; history of present illness; any pertinent past psychiatric, substance use, medical, social, family history; most recent mental status exam; current psychiatric diagnosis including differentials that were ruled out; and plan for treatment and management.

Report normal diagnostic results as the name of the test and “normal” (rather than specific value). Abnormal results should be reported as a specific value.

Pose three questions or discussion prompts, based on your presentation, that your colleagues can respond to after viewing your video.

Be succinct in your presentation, and do not exceed 8 minutes. Specifically address the following for the patient, using your SOAP note as a guide.

Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life?

Objective: What observations did you make during the psychiatric assessment?

Assessment: Discuss their mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses and why you chose them. List them from highest priority to lowest priority. What was your primary diagnosis, and why? Describe how your primary diagnosis aligns with DSM-5-TR diagnostic criteria and is supported by the patient’s symptoms.

Plan: What was your plan for psychotherapy (include one health promotion activity and patient education)? What was your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan. Discuss an identified social determinate of health impacting this patient’s mental health status and provide your recommendation for a referral to assist this patient in meeting this identified need (students will need to conduct research on this topic both in the literature and for community resources).

Reflection notes: What would you do differently with this patient if you could conduct the session again? If you are able to follow up with your patient, explain whether these interventions were successful and why or why not. If you were not able to conduct a follow-up, discuss what your next intervention would be.

A note on grading:

Presenters: Review the Grand Rounds Presenter Rubric attached to this discussion to ensure you meet the scoring criteria.

Participants: Review the Grand Rounds Participant Rubric located on the following Week 4 Assignment 1 page to ensure you meet the scoring criteria. Note the Week 4 Assignment 1 page is for viewing the participant rubric only. Your response should be posted in the forum of this page.

WEEK 4 PRESENTERS:

BY DAY 3

Post your video and your focused SOAP note to the Grand Rounds Discussion forum. You must submit two files for the SOAP note, including a Word document and scanned PDF/images of completed assignment signed by your Preceptor. Then, actively respond to and guide the conversation as your colleagues post responses to your video.

WEEK 4 PARTICIPANTS:

BY MULTIPLE DAYS BETWEEN DAYS 4 AND 7

Respond at least 2 times each to all colleagues who presented this week (should be 2-3 presenters each week). The goal is for the discussion forum to function as robust clinical conferences on the patients. Provide a response to 1 of the 3 discussion prompts that your colleagues provided in their video presentations. You may also provide additional information, alternative points of view, research to support treatment, or patient education strategies you might use with the relevant patient.