Psychosocial/Psych
A patient may derive benefit from a tricyclic antidepressant (TCA) if he experiences depression and:
Chronic pain Amitriptyline and nortriptyline are commonly used in patients who exhibit depression and chronic pain syndromes. TCAs are known to produce mild peripheral vasodilator effects and subsequent relief of pain by an unknown mechanism.
A patient has suspected serotonin syndrome. How can this be diagnosed?
Clinical exam and index of suspicion Serotonin syndrome is a clinical diagnosis characterized by too much serotonergic activity in the central nervous system. There is no way to measure serotonin levels at this time. Therefore, no clinical laboratory or imaging study can identify this syndrome. However, these studies may rule out other conditions.
Which statement about attention deficit disorder (ADD) is correct?
DSM V is used to diagnose a child with ADD ADD and ADD with hyperactivity are two separate diagnoses. This disorder is more common in boys (5:1) and symptoms must be present by age 7 for at least 6 months before diagnosis can be made. DSM V should be used to diagnose children. Parents and/or teachers should establish specific elements. Examples include fidgeting, difficulty remaining in seat, excessive talking, impatient when asked to wait their turn, blurting out answers before time, and interrupting conversation. These must be established in more than one environment.
A 69 year-old female patient reports feelings of anhedonia for the last month. What should be part of the nurse practitioner's assessment?
Depression Anhedonia is the loss of pleasure or interest in things that have always brought pleasure or interest. If this is the case, this patient should be screened for depression. Anhedonia is a red flag for depression.
A patient has been diagnosed with anxiety. What sleep disturbance might she have?
Difficulty falling asleep Patients with anxiety complain of difficulty falling asleep. Patients with depression complain of early morning awakening and difficulty remaining asleep. A manic patient may state that he never feels tired enough to sleep.
Which symptom listed below is typical of depression?
Early morning wakening Sleep difficulty is a common complaint among patients with depression. Patients with difficulty falling asleep are often anxious. Frequent waking and early morning wakening are often complaints by patients with depression. There is no agreed on physiologic explanation, but, this is a common symptom.
A patient with bipolar disease has purchased a $10,000 baby grand piano. He does not play the piano. Consistent with a manic episode in bipolar disease, this is an example of:
Grandiosity During a period of mania, common symptoms are inflated self-esteem and grandiosity (like a buying a baby grand piano), decreased need for sleep, hyper verbosity (excessive talking), racing thoughts and flight of ideas, distractibility, and excessive involvement in pleasurable activities that can be associated with very painful consequences later.
Medications considered first line to treat attention deficit disorder and attention deficit hyperactivity disorder are Schedule:
II Schedule II medications are those described as having a high abuse risk. These can cause severe psychological or physical dependence. Stimulants are used to treat patients with ADD/ADHD because they are thought to affect the dopaminergic and noradrenergic systems that cause the release of catecholamines in the synapses in the central nervous system. Stimulants are considered first line pharmacologic therapy. Specific medication types are methylphenidate, dextroamphetamine, and mixed amphetamine salts. They all have abuse potential and should be prescribed very cautiously.
Which criterion below is a criterion for Alzheimer's Disease?
Impairment of executive function The diagnostic criteria for Alzheimer's disease (AD) was established by DSM V and other organizations. The criteria are similar. Criteria include a gradual onset of cognitive decline. A rapid onset usually indicates another etiology, perhaps, delirium. Other criteria include impairment of recent memory, difficulty with language or finding words, the inability to execute skilled motor activities, disturbances of visual processing or disturbances in executive function that includes abstract reasoning and concentration. Focal neurologic signs are consistent with a vascular dementia. Radiologic evidence is not a criterion for diagnosis, though it may support the diagnosis of AD. There is no laboratory evidence of AD.
A 6 year-old is brought to your clinic because of behavior problems at school. DSM V criteria are used to diagnose attention deficit disorder (ADD). Which finding must be present for this diagnosis?
Inattention There are three categories of symptoms: hyperactivity, inattention, and impulsivity. The diagnostic criteria have been defined by the American Psychiatric Association and can be found in the DSM V.
A patient reports that she takes kava kava regularly for anxiety with good results. What should the NP evaluate?
Liver function studies Kava kava is an herb from the South Pacific that is used to treat anxiety, fibromyalgia, and hyperactivity, attention deficit disorder. Hepatotoxicity has been reported with kava kava use, especially when consumed as tea. Liver toxicity should be reviewed in this patient. If she is not willing to use another agent for treatment of her anxiety, liver function studies should be monitored periodically.
Which findings suggest that a patient may be abusing alcohol?
Macrocytosis, tremulousness, hypertension Findings that should trigger an examiner to suspect alcohol abuse in a patient are tremors, hypertension, rhinophyma, peripheral neuropathy, telangiectasias, and hepatosplenomegaly. A patient does not usually exhibit all of these characteristics. In fact, he may not exhibit any of these symptoms and still abuse alcohol. The symptoms listed in the other choices are not specifically associated with alcoholism. Macrocytosis is common in alcoholics because there is a high rate of B12 deficiency and folate deficiency; both produce macrocytic anemias.
A patient with bipolar disease has purchased a $10,000 baby grand piano. He does not play the piano. This behavior is typical during:
Mania During a period of mania, common symptoms are inflated self-esteem and grandiosity (like a buying a baby grand piano), decreased need for sleep, hyper verbosity (excessive talking), racing thoughts and flight of ideas, distractibility, and excessive involvement in pleasurable activities that can be associated with very painful consequences later.
A 4 year-old is being examined today in the NP clinic. He appears shy and does not make eye contact with the examiner. The mother does not make eye contact with the examiner either. The patient lacks animation and does not smile. What likely possibility must be considered?
Neglect is possible The possibility of neglect should always be given when a young patient and caregiver make poor eye contact with the examiner. Other clues to neglect are a lack of animation and no social smile. Additionally, the child should be observed for nutritional status, behavior, attitude, and physical appearance. Sexual abuse should also be considered, but there is nothing in the stem of the question to suggest this or a lack of medical insurance.
Which patient is most likely to exhibit depression related to his illness? A patient with:
Parkinson's disease Diseases associated with the central nervous system are associated with high rates of depression. These include stroke, Parkinson's disease, multiple sclerosis, and dementia. Other illnesses associated with high rates of depression are cancer and cardiovascular illnesses like myocardial infarction. Depression worsens the outcome of any physical illness.
A patient presents to your clinic numerous times with vague complaints. She seems to respond poorly to medical treatment that is given to her. What should be considered when obtaining a history from her?
Physical abuse or depression Violence is very common in the United States. While men and women are both victims, women are more commonly victims. Patients who have been victims of violence are more likely to utilize healthcare and to have poor response to treatment. If the patient is suspected to have been a victim of violence, they should also be screened for anxiety, depression, and post-traumatic stress disorder.
The preferred medication class to treat patients with an initial episode of depression is:
SSRIs The major classes of antidepressants used to treat depression are listed in this question. Multiple studies have concluded that there is no clear choice on selection of one class over another for efficacy. However, SSRIs are usually the first choice because they are associated with fewer side effects and there is less danger of suicide with an overdose. Monoamine oxidase inhibitors are involved with a number of drug-drug and drug-food interactions and so these are seldom chosen initially.
What are the recommendations for screening older patients for depression?
Screen at each visit. Depression is very common in all adults, especially older adults. Screening can be accomplished easily and quickly in a primary care setting. Untreated depression leads to higher rates of mortality when other co-morbid conditions exist, especially heart disease.
What statement describes depression in older adults?
They can be managed with some of the same medications as younger adults. Depression in older adults is difficult to diagnose because they may present with symptoms such as decreased energy, may associate depressive symptoms with "just getting older" and not mention them to healthcare providers, or they may present with somatic complaints. This last symptom is common in younger adults. Laboratory evaluation should include a CBC, TSH, B-12 level, electrolytes, urinalysis, and others as indicated by history. Many medications used to treat depression in younger patients are used in older patients. The dosages are usually decreased.
The major advantage of the CAGE questionnaire is:
brevity of questions The CAGE questionnaire is a screen for alcohol abuse. It consists of 4 questions that can be quickly and easily incorporated when eliciting a patient's history. The "C" is to remind the questioner to ask the patient whether he's ever felt the need to "C"ut down on drinking; "A"nnoyed by criticism about his drinking; "G"uilty about his drinking; in need of an "E"ye opener. These 4 questions are very easy to ask and can be answered with a simple yes/no response. The majority of patients with alcoholism respond yes to at least 2 of these questions. Patients without alcohol problems virtually never respond "yes" to 2 or more. The questionnaire is known to have high sensitivity and specificity, but is less sensitive for early or heavy drinking.
MMSE helps to identify patients with symptoms of:
dementia The mini mental status exam (MMSE) is a very common and easily administered cognitive evaluation for dementia. It tests orientation, recall, attention, calculation, language manipulation, and constructional praxis. It is not sensitive for mild dementia and may be influenced by educational level and age. Even with these limitations, the MMSE is the most widely used cognitive test for dementia in the US.
Serotonin is thought to play a role in the etiology of:
depression Serotonin (5-HT) is a neurotransmitter released in the brain. It is part of the monoamine oxidase system. These neurotransmitters are responsible for many emotional and behavioral disorders. Agents that cause more serotonin to be available in the brain have an ameliorating effect on symptoms of depression, anxiety, and obsessive-compulsive behavior.
Tricyclic antidepressants may be safely used in older patients who have:
hypothyroidism Tricyclic antidepressants (TCA) are particularly UNSAFE in patients with conduction defects. Use of TCAs can induce bradyarrhythmias and thus can be deleterious for any patient, but especially in older adults who may be prone to this because of conduction defects and underlying myocardial ischemia. Patients with glaucoma and benign prostatic hyperplasia should avoid TCAs as well because of the anticholinergic effects. Selective serotonin reuptake inhibitors (SSRI) should be considered first line for most older patients with depression.
A male patient has a family history of bipolar disorder in two first degree relatives. Bipolar disorder:
often affects multiple family members. There is strong familial component to bipolar disorder. Patients with bipolar disorder have shortened life expectancies. Up to 50% of patients with this disorder will attempt suicide at least once. Approximately 15% will be successful. Risk factors for suicidal behavior in patients with bipolar disorder include family history of suicide attempts, substance abuse, presence of impulsivity or aggression, and frequent depressive episodes.
Delirium differs from dementia because delirium:
often develops acutely Delirium is a change in consciousness or cognition. It may be accompanied by a physical diagnosis like urinary tract infection; or it may be due to consumption of a medication. Regardless, a change in cognition or consciousness needs immediate evaluation. The evaluation should include a medication review, physical exam and laboratory evaluation, and mental status exam.
A common strategy used to minimize the incidence of side effects when giving an elderly patient a selective serotonin reuptake inhibitor (SSRI) is:
prescribe a low dose initially. A principle that is employed when prescribing medications for elderly patients is to "start low and go slow". This should be employed when prescribing SSRIs too. The lowest dose should be a starting point; or a prescriber may order an even lower dose initially. The dose may be slowly increased until therapeutic effects are observed.
A common side effect of trazodone may be alleviated by:
taking this medication at bedtime Trazodone is a tricyclic antidepressant that can produce profound drowsiness. It is often taken at bedtime to induce sleep. This medication should always be taken at bedtime. Trazodone is often given to treat insomnia related to depression or to alleviate the jitteriness and restlessness sometimes associated with SSRI and SNRI use.
Abuse during pregnancy:
tends to occur throughout the pregnancy. Unfortunately, pregnant women are more likely to be abused than non-pregnant ones. When women are abused prior to becoming pregnant, abuse generally escalates during pregnancy. Abuse is not specific to a certain trimester. Abuse during pregnancy tends to occur throughout pregnancy. Because of this, it is important to keep vigilant and re-assess at each prenatal visit.
Depression is diagnosed on clinical presentation. What time frame is important for distinguishing between depressed mood and clinical depression?
2 weeks Screening tests for depression include questions about depressed mood or other symptoms that have lasted at least two weeks. This is an important time frame. Typical screening questions ask: "in the past 2 weeks, have you felt little interest or pleasure in doing things" or "in the past 2 weeks, have you felt down, depressed, or hopeless"?
Which depressed patient below has characteristics that are risk factors for suicide?
78 year old male recently widowed Demographic risk factors for suicide are male gender, older age, having been recently widowed, and living alone. Dentists and other health care workers are at risk for successful suicide because of their knowledge of and access to medications that could be used to commit suicide.
A depressed patient is started on an SSRI. When should another antidepressant be tried if there is no response?
8-12 weeks Most learned authorities agree that if there is no response by 8-12 weeks at a maximal therapeutic dose, a different antidepressant should be tried. The 8-12 week period is an appropriate time frame because it will take this long to increase the dose and attempt to reach maximal dose for therapeutic response. 4-6 weeks is nearing the appropriate time frame, but this may be too short a period of time to reach and evaluate therapeutic effect.
A 76 year-old depressed patient is started on an SSRI. When should another antidepressant be tried if there is no response?
8-12 weeks Most learned authorities agree that if there is no response by 8-12 weeks at a maximal therapeutic dose, a different antidepressant should be tried. The 8-12 week period is the correct time frame because it will take this long to increase the dose and attempt to reach maximal dose for therapeutic response. 4-6 weeks is nearing the appropriate time frame, but this may be too short a period of time to reach and evaluate therapeutic dose.
Which elderly patient is at highest risk of suicide?
86 year-old male with chronic pain and depression Elderly patients are more successful than younger patients when they attempt suicide. Those at highest risk are white males 85 years or older with depression. Symptoms in the elderly which should be of particular concern to healthcare providers are hopelessness, insomnia, unremitting pain, alcohol abuse, restlessness, and impaired concentration.
Which patient is at highest risk of suicide?
86 yr-old male with chronic pain Elderly patients and males are more successful when they attempt suicide. Those at highest risk are white males 85 years or older. Symptoms in the elderly that should be of particular concern to healthcare providers, because they are associated with increased risk of suicide, are hopelessness, insomnia, unremitting pain, alcohol abuse, restlessness, and impaired concentration.
A 70 year-old male patient has an elevated MCV with an anemia. His triglycerides are 420. What should be suspected?
Alcohol abuse This patient has an elevated mean corpuscular volume. This indicates a macrocytic anemia. Common macrocytic anemias are B12 deficiency and folate deficiency. These are common in older patients, especially if they consume large quantities of alcohol. This patient also has elevated triglycerides. Triglycerides are commonly elevated when patients are exposed to alcohol and carbohydrates. This patient's history indicates two elements that indicate alcohol abuse. He should be questioned regarding alcohol abuse.
Mrs. Smith is worried about her eldest child who recently lost his job. She is unable to sleep at night because "she is just so worried she can't sleep." Which medication listed below should NOT be used to treat anxiety in an older adult?
Ambien Zolpidem is a sleep aid, not an anti-anxiety medication. If a benzodiazepine is prescribed, it should be short or intermediate duration. Since benzodiazepines are often abused and can produce cognitive impairment, they should be carefully prescribed. Additionally, they should be prescribed for short-term use only, preferably not more than 60-90 days.
A 19 year-old college student is at least 15% below her ideal body weight. She reports doing well in classes but drinks alcohol nightly, and several cups of coffee throughout the day. She is bradycardic and gets dizzy when she stands. What may also be observed in this patient?
Amenorrhea This patient has anorexia nervosa. She is far below ideal body weight and exhibits evidence of poor nutrition and health. More than 90% of patients with anorexia are amenorrheic. These patients have low levels of leuteinizing hormone and follicle stimulating hormone. Because of prolonged hypoestrogenic states, they are highly susceptible to osteopenia and osteoporosis. It is not known why, but, many patients with anorexia also exhibit mitral valve prolapse, not mitral regurgitation. Because she is bradycardic, an EKG should be performed. QT prolongation is common in these patients, especially when bradycardia is present. Hypotension is more common than hypertension in anorexic patients.
A 19 year-old college student with anorexia is being treated as an outpatient. Today she is bradycardic and occasionally has orthostatic hypotension. What might accompany today's findings?
Amenorrhea This patient has anorexia nervosa. She is far below ideal body weight and exhibits evidence of poor nutrition and health. More than 90% of patients with anorexia are amenorrheic. These patients have low levels of luteinizing hormone and follicle stimulating hormone. Because of prolonged hypoestrogenic states, they are highly susceptible to osteopenia and osteoporosis. It is not known why, but many patients with anorexia also exhibit mitral valve prolapse, not mitral regurgitation. Because she is bradycardic, an EKG should be performed. QT prolongation is common in these patients, especially when bradycardia is present. Hypotension is more common than hypertension in anorexic patients.
The most common co-morbidity associated with depression is:
Anxiety Anxiety is the most common co-morbidity associated with depression; especially panic disorder, obsessive-compulsive disorder, and post-traumatic stress disorder. All of the other choices listed are co-morbidities associated with depression, but do not occur with the same frequency. When these co-morbidities occur in conjunction with depression and are not treated, they worsen the prognosis.
A patient with an eating disorder may concomitantly exhibit:
Anxiety disorders Affective disorders, anxiety disorders, and substance abuse issues are common in patients who have eating disorders. Obsessive-compulsive disorder is also commonly observed. Patients with eating disorders are more likely to have a first or second degree relative with an eating disorder, affective disorder, or alcohol abuse. There is no evidence that patients with eating disorders exhibit a higher incidence of sleep disorders or liver disease. Thyroid disease should always be assessed in patients with eating disorders, but this does not represent the reason for weight loss when eating disorder is present.
A patient with an eating disorder might exhibit evidence of:
Anxiety disorders In patients with eating disorders, it is common to identify affective disorders, anxiety disorders, or substance abuse issues. Obsessive-compulsive disorder is also commonly observed. Patients with eating disorders are more likely to have a first or second degree relative with an eating disorder, affective disorder, or alcohol abuse. There is no evidence that patients with eating disorders exhibit a higher incidence of sleep disorders, or have been sexually abused. Thyroid disease should always be assessed in patients with eating disorders, but this does not represent the reason for weight loss when eating disorder is present.
Elderly patients who are treated for depression with tricyclic antidepressants (TCAs) often exhibit:
Arrhythmias The TCAs have pronounced anticholinergic activity and thus, produce bothersome side effects like dry mouth, constipation, urinary retention, confusion, and even delirium. The TCAs block H1 receptors that may be responsible for sleepiness and weight gain. Hypotension may also result, especially in the elderly. This may be due to an alpha-1 receptor blockade. These medications must be used very cautiously in the elderly because they can produce bradycardia and prolongation of the QT interval. Therefore, a resting EKG is necessary prior to starting any TCA.
A patient with acute anxiety will experience the fastest relief of symptoms when he is treated with:
Benzodiazepine The most rapid relief of anxiety symptoms will occur with a benzodiazepine. The relief occurs with each dose and tapers as the dose is metabolized. The other agents listed will take multiple doses, or days to weeks before relief is experienced. With daily and continued use of benzodiazepines, the anti-anxiety effect may become diminished.
What is the usual age of onset of symptoms for patients with bipolar disorder?
Between 15 and 30 years The usual age of onset of symptoms is between 15 and 30 years. Onset of symptoms almost never occurs in patients older than age 65 years or younger than 15 years.
Which of the following characterizes bulimia nervosa?
Binge eating Recurrent episodes of binge eating characterize bulimia. Loss of control is always present, especially when eating. This results in eating quantities of food far beyond what would normally be consumed. Binge eating is always followed by a compensatory activity. This may take the feature of purging or nonpurging. Nonpurging involves excessive exercise or post-binge fasting. Binges and the compensatory activity occur a minimum of twice weekly for at least 3 months for diagnosis of bulimia nervosa.
Which screen for alcohol abuse has been validated in the elderly?
CAGE CAGE is a screen for alcohol abuse that is validated in adults and older adults. The C stands for "have you ever felt you should CUT down" your alcohol consumption. The A stands for " does other's criticism of your drinking ANNOY you". G stands for "have you ever felt GUILTY about drinking". The E stands for "have you ever had an EYE opener to steady your nerves or get rid of a hangover". A positive response on any question constitutes a positive screen.
Serotonin syndrome may result from taking an SSRI and:
Dextromethorphan Serotonin syndrome is a potentially life-threatening condition. The syndrome occurs when there is too much serotonergic activity in the central nervous system. It can occur with an interaction between two medications, like an SSRI and dextromethorphan, an SSRI and a triptan, an intentional overdose, or with high doses of an SSRI in a particularly sensitive patient. Symptoms of serotonin syndrome include hyperreflexia, clonus, rigidity in the lower extremities, tachycardia, hyperthermia, hypertension, vomiting, disorientation, agitated delirium, or tremor. None of the other medications listed can precipitate serotonin syndrome.
A 38 year-old patient diagnosed with bipolar disease has taken lithium for many months. His mood has stabilized. He was told to report frequent urination while taking lithium. What might be the underlying cause of his frequent urination?
Diabetes insipidus The most common side effect of lithium therapy is nephrogenic diabetes insipidus (NDI). Polyuria and polydipsia secondary to NDI occur in about 20% of patients who take lithium. Lithium accumulates in the collecting tubule cells and causes damage. This leads to changes in antidiuretic hormone (ADH) production, sodium levels, and hypercalcemia. Other changes can occur in the renal system such as mild renal insufficiency. Patients on lithium therapy should be monitored closely for side effects and to ensure that lithium levels are maintained within therapeutic range because lithium has a narrow therapeutic index.
A 45 year-old patient started taking paroxetine one week ago for depression. She calls to report intermittent headache and nausea. What is a likely etiology?
Drug side effect Paroxetine is a selective serotonin reuptake inhibitor (SSRI). Nausea, headache, diarrhea are not unusual symptoms observed in patients who take SSRIs. The symptoms are more common with initiation of therapy and with dose increases. The symptoms tend to subside after a week or so.
A nurse practitioner suspects that a patient is abusing ethanol. What laboratory values would support this suspicion?
Elevated ALT, AST, and GGT Liver enzymes rise in response to acute injury to the liver. ALT and AST are frequently elevated when alcohol abuse occurs. Specifically, the AST is usually the higher of the two enzymes and can signify alcohol abuse when it is more than 2 times greater than the ALT. In patients who abuse alcohol daily, the ALT and AST may be normal. GGT, gamma-glutamyl transferase, is often elevated even when ALT and AST are normal. It can help identify damage to the liver as a result of alcohol abuse.
Which statement about bulimia nervosa is accurate?
High dose SSRIs are used to treat this The medications of choice to treat bulimia nervosa are the SSRIs. Generally, high doses are required. Wellbutrin is not an SSRI and should not be given to patients with eating disorders because of great fluctuations in drug levels related to purging. Generally, this is more common in women than men. Loss of control IS a characteristic of this illness.
A patient presents to the nurse practitioner's clinic and states that she feels sad and thinks she's depressed. What information is important to elicit in order to diagnose her with depression?
How long have you felt like this? In order to diagnose a patient with depression, certain criteria must be met. DSM V has established specific criteria that must be present for a diagnosis of depression to be made. One essential criterion is the presence of depressed mood for at least 2 weeks. If the depressed mood has lasted less than this, a diagnosis is premature. Information about family history supports a diagnosis but is not a criterion. The last two questions assess for risk of suicide.
The nurse practitioner (NP) is treating a 22 year-old for depression with high dose fluoxetine. After several months of dosage changes, she is finally doing well and comes today for a follow up visit. She is happy and states that she might be pregnant. A urine test indicates pregnancy. The NP has referred the patient to an obstetrician who will see the patient in 4 weeks. How should the fluoxetine be handled today?
Let the obstetrician and patient make a decision about continuing fluoxetine Fluoxetine is one of the best studied selective serotonin reuptake inhibitors in pregnancy and lactation. There has been no reported evidence of teratogenicity. While the healthcare provider would rather this patient not take a medication while she is pregnant, consideration must be given to the severity of her depression and her response to treatment. The discussion the NP and obstetrician will have with the patient should include risks and benefits of treatment, and potential risks of stopping fluoxetine. The risk of exposure to medication must always be weighed against the risk of not treating this patient. All psychotropic medications cross the placenta and so developing fetuses are exposed to these medications. Fluoxetine is a category C medication.
An 80 year old adult has begun to use over the counter diphenhydramine to help him fall asleep. What common side effect can occur in older adults with use of this medication?
Next day sleepiness Diphenhydramine should be avoided in older adults. Diphenhydramine exhibits potent anti-cholinergic effects in patients who take this, but especially in older adults. Urinary retention is common (not incontinence) in older men with benign prostatic hyperplasia, but retention occurs in women too. Diphenhydramine is contraindicated in patients with glaucoma. The most serious side effect is cognitive impairment, like daytime sleepiness. Visual disturbances can occur as well as annoying side effects like dry mouth and constipation.
A patient with anorexia nervosa (AN) had symptoms that began about 6 months ago. She presents today and is diagnosed with AN. She has a laboratory evaluation. What might be expected?
Normal lab values Most lab values remain normal until late stages of the illness in patients who are anorectic. The initial lab assessment should include a CBC, glucose, electrolytes, BUN, Cr, and a pregnancy test in females who are amenorrheic.
A 29 year-old postpartum female reports that she is having difficulty with concentration, sleep, and has feelings of guilt. She states that she feels sad most of the time. These symptoms have been present since the birth of her baby about one month ago. She can be diagnosed with:
PPD This patient is correctly diagnosed with postpartum depression. Postpartum depression is diagnosed when depression begins within the first month after delivery. There are 9 symptoms that characterize depression (in non-pregnant patients) and these are used in postpartum patients as well. When a patient exhibits fewer than 5 symptoms, but at least 2 of these symptoms every day for most of the day for at least 2 weeks, s/he may be diagnosed with minor depressive disorder. Depressed mood must be one of these symptoms. If s/he exhibits 5 or more, s/he may be diagnosed with major depressive disorder. In dysthymia, similar symptoms are evaluated, and they must be present at least 2 years. Hypothyroidism can account for feelings of low energy, but hypothyroidism does not produce feelings of guilt or other symptoms associated with depression.
A 79 year-old female lost her husband of 55 years four days ago. She presents today with her daughter because she believes that she is "going crazy". She reports that she often hears his voice though she realizes that he has died. She has not slept well since his death and hasn't eaten very much. She has taken her usual medications for hypertension, osteoporosis, osteoarthritis, and hypothyroidism. She has no history of psychiatric illness. How should the nurse practitioner manage this?
Tell her that this is a normal response and that it will resolve. This imagined hearing or seeing of a deceased person is referred to as "searching behavior" and is not indicative of psychiatric illness. It is a common response after the death of a loved one, especially after 55 years of marriage. This patient and her daughter should be educated regarding the stages of grief and the variable length of each of the stages. Usually by 6 months, grief has begun to resolve, but this is a variable process. She should be encouraged to maintain her usual sleep, nutrition, and activity patterns as much as possible.
How should the nurse practitioner approach a patient who consumes excessive amounts of alcohol but denies that he has a problem?
Tell him that you are concerned about his health. The first step in being able to receive help for a problem is to be able to acknowledge that a problem exists. Since this patient is not willing to acknowledge a problem, but he needs help, one tack is to let him know that you are concerned about his health. If LFTs are ordered, they may not demonstrate elevation; especially if he consumes alcohol every day. Ordering a blood alcohol content, even if positive will be little or no help in having this patient realize that he consumes excessive amounts of alcohol. The provider could tell him to find another health care provider, but, this will do little to get this patient help.
A patient is taking a generic version of a selective serotonin reuptake inhibitor (SSRI). She reports intermittent nausea and mild headache daily since she started this medication 5 days ago. How should the nurse practitioner respond?
These are typical complaints of patients who take SSRIs. Typical symptoms of SSRIs include mild headache, nausea, insomnia, restlessness, and agitation. The emergence of these symptoms is typically dose related and will resolve within 2 weeks. The patient should be encouraged to eat small bites when she feels like she is becoming nauseated and may take acetaminophen or a similar product if the headaches are bothersome. Changing drug classes is also a possibility if the symptoms become too distracting or bothersome.
A 34 year-old bipolar patient has been placed on a fluoxetine and valproate for manic depressive symptoms. He has had great improvement in his symptoms and has returned to work. The psychiatrist has released him to your care. What must be monitored in this patient?
Valproate levels, platelet count, liver function studies Valproate has been associated with liver toxicity and failure, and thrombocytopenia. Liver function studies and platelet counts should be monitored prior to therapy and then regularly as indicated by the drug manufacturer. Valproate levels should be measured to insure target blood level between 50-125 micrograms/mL. Common side effects of valproate are nausea, vomiting, easy bruising, and tremors.
An adolescent female patient with anorexia nervosa must exhibit 4 criteria for diagnosis. Which criterion listed below is NOT part of the diagnostic criteria?
Weight below 90% of ideal body weight Weight below 85% of ideal body weight is the correct criterion. This involves refusal to gain or maintain weight within normal range. Occasionally weight below ideal body range does not involve losing weight, but instead involves refusal to gain weight during a growth spurt. This is commonly observed during pubertal growth spurts and is more common in adolescent females than males. The other three criteria are correct as listed.
A good first choice of antidepressants in an older adult is:
an SSRI An SSRI is a good choice of an antidepressant in an older adult because of the decreased side effects seen when compared with the other agents listed, but especially a TCA. These can produce conduction defects in older adults, sedation, and potent anticholinergic side effects.
The most common mental disorder in older adults is:
anxiety Anxiety is very common in older adults. Depression is very common too, and may accompany anxiety in older adults. The prevalence of anxiety may be due in part to other physical illnesses or serious diseases or disorders, like cancer, Parkinson's disease. New onset anxiety should prompt the examiner to consider withdrawal of medication or side effects of medication being taken at therapeutic levels.
A patient with bulimia nervosa probably has concurrent:
anxiety It is very common that other co-morbidities are present with eating disorders. Anorexia is commonly accompanied by anxiety, especially at mealtimes. Neurotransmitters are thought to play some role in the pathogenesis of anorexia nervosa. This is common in the United States in women especially between the ages of 15 and 30 years. It is relatively uncommon in males.
In patients who exhibit depression, selective serotonin reuptake inhibitors (SSRIs) are commonly chosen as a medication for treatment. SSRIs are often chosen because they
are safer than other medications for depression SSRIs are commonly chosen over tricyclic antidepressants (TCAs) and other medication classes for depression because they have fewer side effects and are thus better tolerated by patients; and because they are safer if overdose occurs. The SSRIs have never been shown to be more efficacious than the TCAs, though publication bias may demonstrate this. Generally, levels of antidepressant medications are not monitored and so laboratory testing is not an issue.
Carbamazepine is used in patients with bipolar disorder for mood stabilization. Prescribers who have patients taking carbamazepine should be alert to:
drug-drug interactions Carbamazepine is an enzyme inducer in the cytochrome P450 system. Consequently, there are a number of drug-drug interactions that can take place as a result. Any time a new medication is prescribed, pharmacist oversight or a drug interaction checker should be employed. Additionally, any time new symptoms develop, medication use and compliance should be assessed.
A patient who abuses alcohol will probably exhibit:
elevated ALT, AST, and GGT Liver enzymes rise in response to acute injury to the liver. ALT and AST are frequently elevated when alcohol abuse occurs. Specifically, the AST is usually the higher of the two enzymes and can signify alcohol abuse when it is more than 2 times greater than the ALT. In patients who abuse alcohol daily, the ALT and AST may be normal. GGT, gamma-glutamyl transferase, is often elevated even when ALT and AST are normal. It can help identify damage to the liver as a result of alcohol abuse.
The clinical difference between minor depression and major depression is:
the number of symptoms present. Major depression is diagnosed when at least 5 symptoms out of nine symptoms (that characterize depression) are identified by the examiner. Minor depression is characterized by the presence of 2-4 of the nine symptoms. Symptoms must be present for at least 2 weeks and must be present most of the day nearly every day. One symptom that must be present is depressed mood. The 9 criteria are identified by the DSM V manual.
A newly diagnosed pregnant teenager has suspected depression. Before a diagnosis is made, she should have a CBC, TSH, renal and liver function tests and:
urine toxicology screen There is a high correlation between psychiatric disorders and drug/alcohol use. This should be ascertained as soon as possible since these can have serious implications on the fetus/mother's health. None of the other tests listed have an impact on diagnosis of depression in a pregnant patient. CBC, TSH, and renal/hepatic function tests are used to screen depression "look a likes" (anemia, hypothyroidism, renal or hepatic dysfunction). Hemoglobin A1C is a good idea but is not as urgent as the urine toxicology screen unless there are diabetes risk factors present.
Within 6 months of treatment, patients who are treated for depression with selective serotonin reuptake inhibitors often exhibit:
weight gain Weight gain is common among men and women who take SSRIs and tricyclic antidepressants (TCAs) because they stimulate appetite. Decreased libido may occur several weeks after starting SSRIs, but this can also be a symptom of depression. The tricyclic and heterocyclic compounds are often associated with blood sugar elevations. Elevations almost never occur within 6 months of starting use. Jitteriness and restlessness are commonly associated with SSRI use. These side effects generally subside after a month or less of therapy.
