Case Study: Armella Ottinger

Armella Ottinger, a 77-year-old African American woman, was widowed almost 10 months ago. She presents with severe anxiety and panic symptoms that have persisted since the death of her husband. She also reports having some short-term memory loss and sometimes waking up at night feeling confused.

Armella was married for 58 years. She is currently living alone in the four-bedroom house where she lived with her husband and raised their five children. All of her children live far away, although she has a sister who lives 20 minutes away whom she sees a few times per month. She has been attending a grief support group at her church for about a month.

Her primary care provider referred her to you, a psychiatric mental health nurse practitioner, for an evaluation and medication management.

Social History

Retired as a school teacher 10 years ago; taught 3rd grade for 40 years. Five adult children all live in California. Lives in Missouri and has limited contact with her children and grandchildren.

Education

Master’s degree in education

Medical History

·  History of back pain, uses Motrin IB 400 mg every 8 hours.

·  History of diabetes type II, takes Metformin 1000 mg daily with meals, last A1C from a month ago was 7.6.

·  History of coronary artery disease, two stents placed 5 years ago.

·  History of hypertension for 10 years, managed with Lisinopril 30 mg daily po.

·  History of rheumatoid arthritis for 20 years, received Rituxan infusions every 4–6 months.

Surgical History

·  Tonsillectomy at 5 years

·  TAH at 55 years

·  Cervical fusion 15 years ago

·  Cardiac stents placed 5 years ago for coronary artery disease

Allergies

Penicillin (hives)

Current Medications

·  Fluoxetine 20 mg at night, has been taking for two months, prescribed by her primary care provider

·  Lisinopril 30 mg daily po for HTN

·  Motrin IB 400 mg every 8 hours for back pain

·  Metformin 1000 mg daily with meals

·  Rituxan infusions every 4–6 months for RA

·  Metoprolol 12.5 mg at night

·  Alprazolam 0.25 mg twice daily for anxiety (used for 2 months, prescribed by primary care provider)

·  OTC multivitamins

Alcohol Intake

Occasional glass of wine with dinner. No other alcohol use.

Nicotine Intake

Denies tobacco use.

Drug Use

Denies drug use.

Sexual Activity

None for many years since her husband had been ill with cancer for 3 years prior to his death.

Questions

From your perspective as Armella’s psychiatric nurse practitioner, address the following:

1.      Write a summary statement about the case presentation, including a potential DSM-5 diagnosis or diagnoses for Armella.

2.      What assessment questions would you ask Armella to identify her anxiety symptoms, triggers, and current coping skills?

3.      What screening tool for anxiety would be appropriate for Armella? If available online, include the link.

4.      What medication changes you would recommend, including doses and administration times? What precautions would you use when prescribing a controlled anti-anxiety medication?

5.      Discuss any other clinical issues that you consider to be significant.