Case Study Scenario:
Mrs. Julie is a widowed 77-year-old retired bank teller who has been brought to the emergency department by her son and daughter as they have been worried about her mood for the past couple of months. This afternoon, when they were both over for a visit, hoping to convince their mom to go out to dinner with the family, Mrs. Julie admitted to them that she felt so terrible that she wanted to die. Her family became very concerned and decided to bring her to the hospital for assessment.
Mrs. Julie was assessed by the emergency physician, who did not feel there were any acute systemic medical illnesses and referred her to the emergency psychiatric team to evaluate her suicidal risk. During her assessment with the on-call psychiatrist, Mrs. Julie admits that she has been feeling lonely and down for about the past 3 months. Her husband of 53 years had passed away 6 months ago suddenly from a massive heart attack. Mrs. Julie thought she managed quite well initially. Even though she was sad that he was gone, she could still do what was needed at the time — making funeral arrangements and dealing with the lawyer and all the necessary paperwork.
Then, about 3 months ago, it all just “hit” her. She was feeling very lonely, particularly at nighttime when she would lie in bed, staring at the ceiling and unable to fall asleep. She continued to feel worse as time passed, walking around the house aimlessly during the daytime, looking for something to do, and eventually ending up sleeping on the couch, so she would no longer have to think. She became increasingly withdrawn and stopped calling her family and friends as she did not feel like talking to anyone.
Mrs. Julie was still keeping up with her personal hygiene but stopped doing housework about a month ago. In the past 2 weeks, she has not felt much like cooking and is just eating crackers and peanut butter. In the past 2 days, she has thought that it would be easier if she could join her husband in death and be at peace.
Before the arrival of her family at her house today, she was looking at her medications and thinking it would be nice to take all of her “sleeping pills” at once. She became very scared by her thoughts. When her children arrived, she told them what she had been thinking. Currently, while she has no plans to kill herself, she is afraid those thoughts would come back when she goes home alone as she does not see any reason to live.
Mrs. Julie states that she has never felt like this before in her life. She has always been a very upbeat and energetic person.
While she may have gone through some difficult periods in the past, she states that she has always managed to get through these times without help. She has never needed to see a psychiatrist for any reason. She denies ever drinking alcohol excessively and denies the use of any illicit drugs.
Medical history revealed that she had a left-side stroke about 10 years ago with full recovery. She has hypertension and hyperlipidemia; these conditions are treated and controlled. Her primary care physician recently told her she is “borderline diabetic.” She also had a significant gastrointestinal bleed about 5 years ago due to a peptic ulcer. She had a remote tonsillectomy and an appendectomy about 15 years ago. Mrs. Julie has a younger sister who went through a “nervous breakdown” after a miscarriage. Mrs. Julie thinks her sister may have been on medication for her “nerves” for a while but does not know of her specific diagnosis or the name of the medication.
Mrs. Julie’s medications included rosuvastatin 10 mg daily, metoprolol 12.5 mg twice daily, aspirin 81 mg daily, pantoprazole 40 mg daily, clopidogrel 75 mg daily, and lorazepam 1 mg every 2 hour as needed (started by her primary care physician after her husband passed away; she takes it about three times a week). Laboratory investigations ordered by the emergency physician included CBC, electrolytes, creatinine (Cr), estimated glomerular filtration rate (eGFR), aspartate aminotransferase (AST), gamma-glutamyl transferase (GGT), alanine aminotransferase (ALT), random glucose, and a urinalysis. Other than a slightly high random glucose of 13.4 mmol/L (241.2 mg/dl), all other blood test results were within normal limits.
Use the SOAP note template to complete the documentation with the information provided.
Formulate appropriate diagnoses and design an appropriate treatment plan.
Explain what further information you will explore to aid in forming an accurate diagnosis.
What treatment management would you recommend for this patient?
How would you predict Julie’s response to treatment?
Discuss clinical judgment and interventions to enhance the client’s safety.
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