Reference no: EM133439156

Case Scenario:

Lillian is a 72-year-old, African American woman living in a rural farming county with her husband and two grandchildren. She comes today accompanied by her husband and 20-year-old granddaughter who have been concerned about increasingly odd behaviors. Lillian has had previous diagnoses of anxiety and obsessive-compulsive disorder. She says she first started hand washing behaviors and counting around the age of 8 years old. She has spent a great deal of her life in and out of psychiatric hospitals this is where she said she started smoking cigarettes. Lillian said that she has smoked over a pack a day for most of her life and had switched to using nicotine patches and gum in her middle 50s.

Nicotine gum is a type of chewing gum that delivers nicotine to the body. It is used as an aid in nicotine replacement therapy (NRT), a process for smoking cessation. The nicotine is delivered to the bloodstream via absorption by the tissues of the mouth. The pieces are usually available in individual package come in various flavors. Individuals are directed to chew the gum until it softens, and the gum is then "parked," or tucked, in between the cheek and gums chewed again until taste returns and is then re-parked in a new location. These steps are repeated until the gum is depleted of nicotine (about 30 minutes as the craving dissipates.)

Using NRT supported Lillian to stop smoking; however, she said that to this day she still feels anxious about chewing the gum and has often expressed the desire to cease altogether. She has been counting how many times she chews and has little time for much else.

Lillian disclosed that she was chewing a significantly high amount of gum and was often going to bed chewing it and had woken up choking on the gum at night. Lillian also explained that she believed that the gum chewing over the past few years was problematic, and that she was expecting to be diagnosed with lung cancer at her PCP appointment next week. She has been counting how many times she has been coughing on gum and is alarmed. Lillian became very anxious when speaking about this. She explained that she thought nicotine could give her cancer.

Lillian's husband has been worried about her dose of antianxiety medication not being sufficient or that she has not been taking it. He has found her way out in their soybean fields counting the rows. Recent stressors are the death of a close friend from COVID-19 and her granddaughter's plans to move out next month to go to an out of state university. She has a family history of alcohol use disorder (father) and anxiety (mother). Son had treatment for opioid use disorder (OUD) but has been in recovery for 1 year. She has a grandson who she can't see because there is a restraining order against her son and the rest of her family.

Medical Problems: Hypertension, Anxiety, Occasional incontinence, Hyperlipidemia, Gastroesophageal reflux disease, B12 deficiency, Allergic rhinitis, Glaucoma.

Laboratory Results: Leukocytes: 5,700 cells/mcL, RBC: 3.02 million cells/mcL, Hgb: 8.1 g/dL, HCT: 25.2%, MCV: 83 fL, MCH: 26.5 Hgb/cell, MCHC: 32%, RDW-CV: 15.8%, Platelets: 150,000 cells/mcL, Glucose: 92 mg/dL, Blood urea nitrogen (BUN): 34 mg/dL, Creatinine: 1.4 mg/dL, GFR: 38 mL/minute/1.73 m2.

Current Medications: Valsartan 80 mg daily. Citalopram 40 mg daily, Gabapentin 300 mg tabs 2 tabs three times daily. Tylenol 500 mg one to two four times daily prn. Brimonidine tartrate 0.15% ophth 1 drop OU twice daily 13. Cosopt 2%-0.5% 1 drop OU at hs. Latanoprost 0.005% 2 drops OU at hs. Trazodone 25 mg at hs. Calcium carbonate 500 mg 1-2 tabs three times daily.

Constitutional: Vitals: Head: ENMT: CV: Respiratory: GI: This is a thin, alert, older African American female in no apparent distress, pleasant and cooperative, but with a notably flat affect. Supine - 135/76, 69; Sitting - 112/75, 76; Standing - 116/76, 75. BMI 19. Normocephalic / atraumatic. Wearing glasses. Acuity 20/30 R, 20/70 L. Regular rate and rhythm normal S1/S2 without murmurs, rubs, or gallops. Clear to auscultation bilaterally. Normal bowel tones, soft, non-tender, non-distended. Musculoskeletal: Strength: UE strength 5/5 B biceps, triceps, deltoids; LE strength 4+/5 bilateral hip flexors and abductors; 4+/5 bilateral knee flexors/extensors; 5/5 bilateral AF/AE; 5/5 bilateral DF and PF. No knee joint laxity. Foot exam shows no calluses, ulcerations, or deformities. Neurology: Whisper test for hearing: Tone/abnormal movements: Psych: Cognitive screen: recalled 3/3 items. Intact. Tone is mildly increased in both legs, normal tone in both arms. Sensation is intact to light touch and pain throughout. Reflexes are normal and symmetric. PHQ-2 = 4/6. A mini-mental status exam was administered, and she scored 22/30, indicating mild cognitive impairment.

Questions: After viewing the patient interactive information, address the following:

1. What important information is missing from the case study?

2. Discuss normal developmental achievements and potential vulnerabilities.

3. What precipitating factors could be contributing to the current symptoms?

4. What is the differential diagnosis?

5. Describe the etiology of the primary diagnosis.

6. How should physiologic complications be monitored and assessed?

7. What are the usual nonpharmacologic therapies that would help?

8. What medications could help and why?

9. Identify safety risks and how they should be dealt with in the treatment plan.