Question

Depression Case Study

Subjective

Mr. AK is a 45 yr old African American male who is referred to begin pulmonary rehabilitation. His chief complaint is worsening shortness of breath with exertion due to sarcoidosis involving the lung. He reports that he can now only walk less than 0.75 mi on a flat surface; he cannot walk more than one and one-half flights of stairs without stopping. He states that prior attempts to improve functional capacity through regular exercise or increasing activity habits have fallen short due to disinterest, fatigue, and his dislike for exercising in front of others.

Mr. AK also suffers from grade I obesity, depression, hypertension, and hyperglycemia. Family history indicates that his father, mother, and both sisters are living. Social history indicates that he is married with one child (14 yr of age). He works part-time from home as a graphic artist, he does not routinely exercise, his daily activities are markedly restricted due to shortness of breath, he does not smoke or drink, he has difficulty falling asleep at night and awakening in the morning, and he denies substance abuse. Patient is being cared for by Behavioral Health Clinic, which includes ongoing psychotherapy to manage depression, and by his primary care physician for management of hypertension and diabetes.

He is allergic to penicillin. Medications include methotrexate, prednisone, hydrochlorothiazide, and glipizide.

Objective and Laboratory Data

Patient is a mildly obese male (BMI = 33.4) in no acute distress. Lung volumes and forced expiratory flow rates are reduced per recent spirometry report in medical record, as is lung diffusing capacity. Skin nodules observed on neck, arms, and legs; lungs clear; and cardiovascular examination unremarkable and without evidence of edema. Resting heart rate 86 beats · min^–1 and resting blood pressure 144/96 mmHg. Spleen and liver enlarged. Depression screening with PHQ-9 scored at 9.

Assessment and Plan

Patient has active sarcoidosis involving lung, with second organ involvement including skin, liver, and spleen. Comorbidities include hypertension, hyperglycemia, obesity, marked deconditioning, and sleep disturbance likely due to depression (PHQ-9 score = 9).

Mr. AK completed an exercise test using a stationary cycle, achieving a peak power output of 87 W, and stopping due to dyspnea. Peak heart rate 145 beats · min^–1 and peak blood pressure 194/100 mmHg. Oxygen saturation fell from 97% at rest to 89% at peak. No ECG ST segment observed, chest pain denied, and isolated PVCs observed.

Plan includes initiating weight management for obesity and enrolling in pulmonary rehabilitation to improve functional capacity and decrease shortness of breath.

In addition to improving functional capacity through aerobic-type large muscle activities, will include respiratory muscle training, as well as upper body strength training to improve skeletal muscle strength and endurance. Monitor oxygen saturation and use oxygen supplementation via nasal cannula, as needed, to maintain oxygen saturation at 90% or greater. To ensure sufficient stimulus and to enhance patient compliance, intensity for aerobic training is set at 3-5 on 10-point Dyspnea scale. Duration of effort should progress to 30 min, but interval work may be needed if patient is initially unable to exercise for 30 continuous min. Frequency of aerobic activity set at 3 times per week and resistance training set at 2 times per week (2 sets of 12-15 repetitions).

Case Study Discussion Questions

1. Take a moment and research the PHQ-9 as a screening tool for depression. In the clinical setting, values of 10 or higher usually warrant referral to Behavioral Services or informing the patient’s primary care provider. With a value of 9, as reported in Mr. AK, what might you draw from this value relative to influencing compliance, patient affect, and group interaction in the rehabilitation setting?
2. What symptoms should you monitor to decide whether Mr. AK’s depression is worsening while he is participating at your center? If he was worsening, how would you handle this situation?
3. Is regular exercise an effective treatment for depression? Is exercise training/rehabilitation more, less, or similarly effective when compared to medical therapy or cognitive–behavioral therapy? Explain.

Chapter 34

Intellectual Disability Case Study

Subjective

Mr. RK is a 45 yr old male who has a mild intellectual disability (ID) and also Down syndrome (DS) and early stage Alzheimer’s disease. He lives in a community group home with 24 h support and assistance. He works 6 h per day at a local fast food restaurant. His favorite activity is to watch TV, and he enjoys eating popcorn while watching movies.

He does not have any history of heart disease or other serious medical conditions. His case worker has noted that over the past year he has experienced increased shortness of breath when walking up the stairs to his bedroom. However, at his last physical examination there was no note on any suggested pulmonary problems. He has started to display the early stage of Alzheimer’s disease and medical record notes abnormal laxity of the left knee. Mr. RK cannot walk or jog for any extended period of time without pain.

Both his physician and case worker have encouraged him to become more physically active, but at present he performs no physical activity outside of work. He is not currently taking any medications. He is referred by his physician with a request that he be provided assistance with beginning a mild exercise regimen.

Objective and Laboratory Data

He is 5 ft 6 in. (168 cm) and 240 lb (109 kg), with a BMI of 38.8 kg · m–2. Recent laboratory data indicates his total cholesterol is 240 mg · dL–1, with high-density lipoprotein (HDL) cholesterol of 35 mg · dL–1. There is no information on triglycerides or low-density lipoprotein (LDL) cholesterol. His blood pressure was 110/70 mmHg. Other findings on the physical examination were unremarkable.

A graded exercise test was ordered and completed. Mr. AK completed 4 min on a standard Bruce treadmill protocol. His maximal heart rate was 148 beats · min–1 (85% of predicted), and his maximal work capacity was predicted from treadmill time to be 4 METs. Oxygen uptake was not measured. His maximal blood pressure was 150/80 mmHg. He exhibited no ECG abnormalities, and the test was interpreted as negative for exercise-induced myocardial ischemia; but it was noted that maximal effort may not have been reached as evidenced by the low maximal heart rate achieved.

Assessment and Plan

Mr. RK has a mild ID with DS and early stage of Alzheimer’s disease. He is obese and presents with several cardiovascular disease risk factors.

A supervised exercise plan is established. Since Mr. RK has a problem with knee instability and knee pain, he was prescribed a stationary cycling program.

Case Study Discussion Questions

4. Provide a more specific exercise program. Include your recommendations for intensity, duration, frequency, as well as how you would progress the exercise.
5. What measures might you use to evaluate progress and outcomes? Explain your rationale for your choices.

Answer 1

Depression Case Study

Case Study Discussion Questions

PHQ-9 Score.

• 0-4-minimum or none
• 5-9-mild
• 10-14-moderate
• 15-19-moderately severe
• 20-27-severe.

Here score of Mr, AK is 9, that means the condition is mild only. He denied exercise due to disinterest, fatigue and dislike in front of others. He is obese and feels difficulty in sleeping at night waking up in the morning. In order to find whether his condition is worsening or not the symptoms that need to monitor is 1. his interest in doing exercise 2.whether, he is fatigue or not.3. Doing exercise in front of others still exist 4.whether he is loosening weight.

If the condition is worsening along with exercise start psychotherapy

Regular exercise alone will cure depression unless the patient is fit medically. Here the patient is having sarcoidosis and other conditions which restricts his exercise.

Intellectual Disability Case Study.

Mr.RK has mild intellectual disability with downs syndrome. He has knee pain and knee instability. Also, he has underlying cardiac conditions. So exercise should be heart-friendly.

Every exercise should start slowly and gradually increase the intensity. The following exercise can be done safely

1. Walking .: Start walking 19to 20 days and gradually increases up to 30to 40 minutes

2. Running: Slow running is preferred.

Both these excise may increase his heart rate, already it is high.