Question

Miss R is an 18 year-old white female college student who was recently hospitalized for major depression. Her mother calls the primary care office where the nurse is employed and shares concerns about her daughter’s agitation and hostility telling the nurse that her daughter is “pacing the halls at night and doesn’t sleep much. She isn’t eating. The mother says, “When I ask her what’s wrong, she shuts her door, telling me she doesn’t want to talk now. The few people she’ll talk to are suspicious characters, not her usual group of friends. I think they’re using drugs.”

Miss R’s mother then tells you that her daughter’s condition has deteriorated since the brief hospitalization 4 days ago, when she was started on her medications.

The nurse has seen Miss R in the past and has a good relationship with her. The nurse convinces her come to the clinic to be evaluated.

Miss R arrives at the clinic appearing agitated. She admits that she has been “nerved up” and “full of energy,” but she can’t understand why her mom is so concerned. She tells the nurse: “My depression is starting to lift. I’m actually starting to see the world in vivid color. Yeah, I have new friends, because I’m starting to live again. No, I’m not using drugs. I drink once in a while, sometimes more than I should.”

When questioned further about her mood, Miss R. admits that “Sometimes at night, I get nervous and start to get those dark thoughts that made me miserable this past year, but I no longer want to hurt myself. I want to live.”

Past Medical History:

Anorexia/Bulimia

Possible ADHD (poor school performance, never fully worked up)

Depression (several episodes since age 14, most serious 2 weeks ago, when she considered suicide following break-up with boyfriend)

Seasonal allergic rhinitis

Medications:

Imipramine (Tofranil), 150 mg, PO, qhs

Cimetidine (Tagamet), 800 mg, PO, bid, for indigestion/heartburn, obtained OTC, started 1 week ago

Loratadine, 10 mg, PO, daily

Loestrin 21 (1.5/30), tablet PO, daily

Allergies:

Sulfa drugs cause hives

Physical Exam:

Vital signs: BP: 125/78, HR: 108, RR: 20, T: 37.5

Hypervigilant, anxious, thin female, pacing the room

Dressed casually, appropriate for setting

Speech: somewhat pressured, loud

Neuro: Attention poor- starts out window instead of answering some questions

              Thought content logical and relevant

              Oriented x3, no focal neurological signs

Q1: Should the nurse be concerned about this patient’s behavioral changes? What might be going on with this patient?

Q2: Are insomnia and increased energy likely side effects of this patient’s antidepressant medication?

Q3: Are there drug interactions between this patient’s medications that are concerning? If so, list them. Hint: cimetidine is a CYP450 inhibitor

Q4: Is there anything that should get the nurse’s attention on the physical exam?

Q5: Given her history and the findings on today’s examination, are there safer medications for this patient?

Answer 1

1.The nurse should be concerned about the patient's behavior because she is exhibiting some of the side effects of the drugs like increased behavioural disorders, insomnia, agitation, not eating well ,tachycardia .The patient may be at risk of serotonin syndrome which has to assesed and addressed

2.Insomnia and increased agitation are some of the likely side-effects of this drug .

3.The cimetidine interacts with the anti depressant drug

The Loestrin is a CYP3A4 inhibitor

This can interact with the medication absorption and decrease the absorption .

4.The nurse should pay attention on the use of alcohol once in a while because this can interact with the drug like imipramine. The tachycardia has to examined further to prevent any unnecessary consequences .

5.An alternative which can have minimal side effects and safer is class of medication belonging to selective serotonin reuptake inhibitors.