Written Objective Structured Clinical Assessment

Student name: Azinwi Clariece Nyah

Modulecode: 6012SOH
Student number: 12238086

The sections are as follows:

i) Details of the consultation and history taking. Describe how you undertook this
and what information you gathered. Details to focus on would include the
patient’s: age, gender, past medical history, drug history, presenting condition
managed, gaining consent and how you ensured concordance / understanding.
ii) What have you decided to prescribe and why, what is your diagnosis? What is
the dose, regimen and route of administration? Justify your prescribing decision
in the light of your consultation and history that aided you determining your
diagnosis and plan. What other action did you take, did you recommend other
non-pharmacological managements or activities? Did you request further
investigations or refer to other professionals if necessary? What was your
consideration of the potential for adverse drug reactions or interactions? Is your
prescribing decision suitable for your patient, their needs and requirements, is it
practical?
iii) Write an appropriate, valid and legal FP10 prescription based on you
consultation and decision. Remember that any mathematical calculations
relating to dose, regimen or quantities of medication must be correct and any
prescription that would clearly do harm to the patient would be an automatic
fail.
(Staff Use Only) PASS / FAIL
Consultation skills and history taking

Decision making and rationale

Prescription writing

Comments Over all

PASS / FAIL
Describe the consultation you undertook with the patient in order to
complete a full and appropriate history and gain consent.

 Patient attended clinic for his Psychiatric review accompanied by his wife.
 Greeted him and his wife followed by my introduction as Clariece and my title as
an independent mental health nurse (MHN) prescriber.
 Complimented their outfits as stunning and welcomed them to sit down. I ensured
they were comfortable and asked if they needed a drink to help them feel
welcome and relaxed, they declined and gestured they were fine.
 Consent was given by the patient and proceeded to confirm his name with him as
Billy Jackson, 68 years old.

Problem: Moderately severe depression – issues of irritability, ‘empty mood’, and

persistent sadness.

History
 Patient had already spoken to his general practitioner (GP) about suffering from
‘empty’ mood, panic attacks, feelings of hopelessness, sadness, and anxiety for a
few weeks alongside a six months history of inability to sit still and fatigue.
 Having poor sleeping patterns, regular episodes of anxiety, poor concentration,
lack of appetite which hinders him from having a balanced diet, and sometimes
really struggling with interest in doing his typical daily tasks such as taking
showers.
 Established past treatment with behavioural activation (BA) therapy for 2 months
but did not seem to improve his depression and ‘empty’ mood and ended up
giving up on the treatment.
 Asked if for the last two weeks he had often been bothered by feelings of
hopelessness, depression, anxiety, irritability, or hopelessness which he answered
‘yes’. He denied going through any symptoms of change in mood but added that
his experiences made him less productive at his antique store.
 Asked if he was losing interest in things that he used to enjoy in the past; which his
wife mentioned as watching football and fishing; which he said yes because they
were not fun to him anymore.
 Assessed with consent using the 9-item Patient Health questionnaire (PHQ-9) and the
Beck Depression Inventory (BDI -II).
 Stated no family history of generalised anxiety disorder or depression
 Also described feeling demotivated and struggling to get out of bed in the morning
and that his symptoms happened several times a day.
 Established that he did not have any thoughts of committing suicide or self-harm
until the last two weeks when he started feeling down and weak which made him
feel like he wasn’t important in this world anymore but did not think about
suicide.
 Described that he changed his mind after imagining what his family would go
through and denied having any such plans despite having a history of self-harm
when he was 50 years old.
Medical history
 No history of treatment with anti-depressants or psychedelics
 History of psychotherapy treatment – BA
 Stated using herbal medicine saffron for 5 weeks but stopped a month ago.
 His wife added that he was allergic to Serotonin (after using it on burn injury on his
right elbow)
 No other relevant medical treatment or diagnosis

Social history
 Established that he is worried about his work which according to his wife he values
the shop a lot and it made it worse when he imagined that he was going to let it
go after it just started recovering from the economic effects of the Covid-19
pandemic.
 Stated that they have three children who live abroad in Spain
 Asked him about his use of alcohol and other substances and answered that he
doesn’t smoke but at times he drinks (for the last 6 months) when feeling anxious
or in low mood even after successfully quitting alcohol 20 years ago.
 Does not use any other recreational drugs
 Physically inactive and socially isolated for the last two years

Patient’s expectations and treatment priorities

 Answered that he had been trying to alleviate his mood and motivate using
Saffron herbs but did not have positive outcomes on any of the current symptoms.
He added that he had tried psychotherapy – BA – but didn’t work as expected so
he would be happy to try something new, prescribed drugs since his wife would
help him adhere to the medication.
 He wanted affordable medication that would help fight his depressive symptoms
including alleviate his mood, motivate to work and interact with friends and
family, and improve concentration so that he can work at his shop.

Based on your consultation and history taking above, demonstrate the rationale for your
prescribing decision and wider safe management of the patient.

The patient scored 23/27 on thePHQ-9 tool and 33/63 on the BDI-II inventory assessment
tool, and, considering the symptoms and his medical history above, I do think he is
suffering from moderately severe depression.
 Conducted differential diagnosis to assess for the symptoms of depression and
anxiety but they revealed an onset of depression through the PHQ-9 tool
moderately severe depression which was justified through the BDI-II inventory
tool.
 Inquisition about experiencing any sudden changes in mood helped to rule out any
cases of bipolar disorder since he wasn’t experiencing mania.
 His reply that he started using alcohol because of depressive symptoms was
sought to establish if he needed a specialist in drugs and substance abuse.
 However, he promised to stop in his wife’s presence but plan was to go ahead and
refer him to local drug and alcohol services known as R3.
 He had also stopped using Saffron and the question about using any drugs helped
to check if he was using any drugs that might react with antidepressants.
 Asking about his allergies helped in eliminating antidepressants that contain or
react with Serotonin and avoid negative side effects.
 Blood tests from his GP indicated no abnormalities and this helped to eliminate
any pathological causes of signs like tiredness, lack of sleep, and loss of appetite.

The treatment plan

The patient assessment tool PHQ-9 demonstrate that the patient had depression
which got worse as a result of a change in his lifestyle with notable changes in social
life, family interactions, and his business which are risk factors for depression. Its
severity was indicated by the BDI-II tool as moderate.
 The patient wasn’t suicidal despite having a little history of self-harm over 10 years
ago and if so, I would have referred him to the mental health team
emergency/crisis Team. Alternatively, I would have considered asking for my
supervisor’s advice if unsure about the patient's ideal treatment plan. However, I
still referred him to the in-house Psychologist against potential instances of self-
harm.
 Minimal safeguarding concerns since the patient affirm that the wife was
supportive and there were no family fights or disagreement of concern.
 The only medication used by the patient was the Saffron herbs. I advised him not
to resume taking the herbs it is likely to increase the risk of serotonin syndrome as
it has an interactive side effect.
 No contraindication, GI bleeding issues, and no NSAIDs OTC were reported based
on the medical history.
 When the patient's low mood was mild, BA therapy was employed. However, the
conditions have changed due to lack of improvements. Therefore, it is not a
practical intervention for him so a different form of therapy, face-to-face cognitive
behaviour therapy – CBT hence my referral to Psychology.
 The treatment plan is to begin with an antidepressant (that has the minimal
effects on serotonin levels) combined with CBT. The functioning of antidepressants
was explained to the patient, highlighting how his moods could be alleviated. I
have also explained that, for positive outcomes, the antidepressants needed to be
continued for 28 days. Combing the treatment with CBT which can help to manage
his mood.
 On selecting an antidepressant, it was crucial to incorporate the patient’s
preferences.
 On side effects profile, dizziness, sedation, suicidal profile, GI discomfort, and
nausea (information leaflet, present inbox, can be referred to). The patient lives at
home with his wife and feels he can manage side effects better as he was advised
to relax at home. The side effects should improve within two weeks, and he is
advised to contact me if any issues arise.
 No more contraindications cautions or ADRs. However, some alternatives can be
discussed if the side effects got worse or his mood fail to improve.
 The prescription:
 I decided to start with a daily 30mg of Mirtazapine oral tablet once a day as per
the BNF provisions on moderately severe depressive disorders among the elderly
for 28 days (28 tablets) due to its verified effectiveness and absence of pro-
serotonergic activity.
 He should take the medication before bed once day, in the evening after meals
before going to bed.
 The patient is happy and satisfied with the treatment and plan. He is happy that
the treatment is ideal for him and understands its role against depressive
symptoms.
 An appointment between the patient and I was pre-scheduled in 4 weeks, and a 2-
3 weeks appointment will be scheduled after the first visit.
 The rationale for this is that the symptoms take at least a month to improve, and
for the first 2 months, 1 week appointments should be booked, but they can be
more frequent if need be.
 I have encouraged the patient not to stop the medication suddenly unless this has
been discussed with a clinician to avert withdrawal effects but advised that the
medication is not addictive.
 I advised the patient to book an appointment if he experiences any issues so they
can be discussed with the clinician.
 Advice was issued on moderately severe depression, and vital resources were
signposted.
 Advised him not to miss any appointments alongside the CBT appointments to
facilitate fast positive outcomes.
 The patient was advised to go for walks and engage in regular exercise to help
enhance his mood. He should also find productive tasks that will keep him busy
and distracted.
 The patient was also advised to refer to a talking space to assist him cope with
negative emotions and positive approaches to life.
 Links to support websites were sent via text: +447565874990
 Phone number given for emergencies +447762590220
 There were no further questions on the treatment plan, the patient appeared to
understand as advised/directed as per required monitoring.

Pharmacy Stamp Age Title, Forename, Surname & Address

Mr. BILLY JACKSON
67
89-92 Park Lane, Croydon CR3 1JJ England
D.o.B

Please don’t stamp over age box 12/07/1954 NHS Number 123 456 7890
Number of days’ treatment 28
N.B. Ensure dose is stated
 CN
Endorsements INDEPENDENT / SUPPLEMENTARY PRESCRIBER

Mirtazapine 30mg
(1 tablet)

Once a day

Before sleeping at
night after meal

Signature of Prescriber Date

30/06/2022

CN
For Independent prescriber
dispenser A. C. Nyah
No. of
Prescns. Anywhere PCT
on form
PATIENTS PRACTICE CODE 1278100
TRUST HQ, HOSPITAL CAMPUS
ANYWHERE
PQ99 6PQ
01604 8912345 /01234 567890
NURSE CONTACT TEL. NO 01234567890