Depression Case Study
Subjective
Mr. AK is a 45 yr old African American male who is referred tobegin pulmonary rehabilitation. His chief complaint is worseningshortness of breath with exertion due to sarcoidosis involving thelung. He reports that he can now only walk less than 0.75 mi on aflat surface; he cannot walk more than one and one-half flights ofstairs without stopping. He states that prior attempts to improvefunctional capacity through regular exercise or increasing activityhabits have fallen short due to disinterest, fatigue, and hisdislike for exercising in front of others.
Mr. AK also suffers from grade I obesity, depression,hypertension, and hyperglycemia. Family history indicates that hisfather, mother, and both sisters are living. Social historyindicates that he is married with one child (14 yr of age). Heworks part-time from home as a graphic artist, he does notroutinely exercise, his daily activities are markedly restricteddue to shortness of breath, he does not smoke or drink, he hasdifficulty falling asleep at night and awakening in the morning,and he denies substance abuse. Patient is being cared for byBehavioral Health Clinic, which includes ongoing psychotherapy tomanage depression, and by his primary care physician for managementof 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 acutedistress. Lung volumes and forced expiratory flow rates are reducedper recent spirometry report in medical record, as is lungdiffusing capacity. Skin nodules observed on neck, arms, and legs;lungs clear; and cardiovascular examination unremarkable andwithout evidence of edema. Resting heart rate 86 beats ·min–1 and resting blood pressure 144/96 mmHg. Spleen andliver enlarged. Depression screening with PHQ-9 scored at 9.
Assessment and Plan
Patient has active sarcoidosis involving lung, with second organinvolvement including skin, liver, and spleen. Comorbiditiesinclude hypertension, hyperglycemia, obesity, markeddeconditioning, 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 bloodpressure 194/100 mmHg. Oxygen saturation fell from 97% at rest to89% at peak. No ECG ST segment observed, chest pain denied, andisolated PVCs observed.
Plan includes initiating weight management for obesity andenrolling in pulmonary rehabilitation to improve functionalcapacity and decrease shortness of breath.
In addition to improving functional capacity throughaerobic-type large muscle activities, will include respiratorymuscle training, as well as upper body strength training to improveskeletal muscle strength and endurance. Monitor oxygen saturationand use oxygen supplementation via nasal cannula, as needed, tomaintain oxygen saturation at 90% or greater. To ensure sufficientstimulus and to enhance patient compliance, intensity for aerobictraining is set at 3-5 on 10-point Dyspnea scale. Duration ofeffort should progress to 30 min, but interval work may be neededif patient is initially unable to exercise for 30 continuous min.Frequency of aerobic activity set at 3 times per week andresistance training set at 2 times per week (2 sets of 12-15repetitions).
Case Study Discussion Questions
- Take a moment and research the PHQ-9 as a screening tool fordepression. In the clinical setting, values of 10 or higher usuallywarrant referral to Behavioral Services or informing the patient’sprimary care provider. With a value of 9, as reported in Mr. AK,what might you draw from this value relative to influencingcompliance, patient affect, and group interaction in therehabilitation setting?
- What symptoms should you monitor to decide whether Mr. AK’sdepression is worsening while he is participating at your center?If he was worsening, how would you handle this situation?
- Is regular exercise an effective treatment for depression? Isexercise training/rehabilitation more, less, or similarly effectivewhen 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 intellectualdisability (ID) and also Down syndrome (DS) and early stageAlzheimer’s disease. He lives in a community group home with 24 hsupport and assistance. He works 6 h per day at a local fast foodrestaurant. His favorite activity is to watch TV, and he enjoyseating popcorn while watching movies.
He does not have any history of heart disease or other seriousmedical conditions. His case worker has noted that over the pastyear he has experienced increased shortness of breath when walkingup the stairs to his bedroom. However, at his last physicalexamination there was no note on any suggested pulmonary problems.He has started to display the early stage of Alzheimer’s diseaseand medical record notes abnormal laxity of the left knee. Mr. RKcannot walk or jog for any extended period of time withoutpain.
Both his physician and case worker have encouraged him to becomemore physically active, but at present he performs no physicalactivity outside of work. He is not currently taking anymedications. He is referred by his physician with a request that hebe 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 of38.8 kg · m–2. Recent laboratory data indicates his totalcholesterol is 240 mg · dL–1, with high-density lipoprotein (HDL)cholesterol of 35 mg · dL–1. There is no information ontriglycerides or low-density lipoprotein (LDL) cholesterol. Hisblood pressure was 110/70 mmHg. Other findings on the physicalexamination were unremarkable.
A graded exercise test was ordered and completed. Mr. AKcompleted 4 min on a standard Bruce treadmill protocol. His maximalheart rate was 148 beats · min–1 (85% of predicted), and hismaximal work capacity was predicted from treadmill time to be 4METs. Oxygen uptake was not measured. His maximal blood pressurewas 150/80 mmHg. He exhibited no ECG abnormalities, and the testwas interpreted as negative for exercise-induced myocardialischemia; but it was noted that maximal effort may not have beenreached 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’sdisease. He is obese and presents with several cardiovasculardisease risk factors.
A supervised exercise plan is established. Since Mr. RK has aproblem with knee instability and knee pain, he was prescribed astationary cycling program.
Case Study Discussion Questions
- Provide a more specific exercise program. Include yourrecommendations for intensity, duration, frequency, as well as howyou would progress the exercise.
- What measures might you use to evaluate progress and outcomes?Explain your rationale for your choices.
