Assignment Week 9 – NRNP 6635 – Case Study
Assignment Week 9 – NRNP 6635 – Case Study
ASSIGNMENT INSTRUCTIONS:
- Select a patient that you examined during the last 2 weeks who presented with a disorder (See attached Case study – Week # 9)
- Conduct a Comprehensive Psychiatric Evaluation on this patient and use the template provided to complete the assignment. There is also a completed exemplar document that you can see an example of the types of information a completed evaluation document should contain. ( see attached documents)
- Include at least five (5) scholarly resources to support your assessment and diagnostic reasoning.
- Report normal diagnostic results as the name of the test and “normal” (rather than specific value). Abnormal results should be reported as a specific value.
- Subjective:What details did the patient provide regarding their personal and medical history? What are their symptoms of concern? How long have they been experiencing them, and what is the severity? How are their symptoms impacting their functioning? Assignment Week 9 – NRNP 6635 – Case Study
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- Objective: What observations did you make during the interview and review of systems?
Assessment: What were your differential diagnoses? Provide a minimum of three (3) differentials with supporting evidence. List them from highest to lowest priority. What was your primary diagnosis and why? Explain what rules each differential in or out and justify your primary diagnosis selection. Include pertinent positives and pertinent negatives for the specific patient case.
Reflection notes: What would you do differently in a similar patient evaluation? Reflect on this case and discuss whether or not you agree with your preceptor’s assessment and diagnostic impression of the patient and why or why not. What did you learn from this case? What would you do differently?
Also include in your reflection a discussion related to legal/ethical considerations (demonstrating critical thinking beyond confidentiality and consent for treatment!), health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).
Demographics: Female, 41 years-old Hispanic on disability. The higher level of education High School.
Setting: Private Office, follow up appointed after discharged from inpatient psych admission.
Reason for and Type of Visit: “I was admitted to a mental institution for five days after I tried to kill myself taking an overdose in my medications. They discharged me from the hospital three days ago.” Assignment Week 9 – NRNP 6635 – Case Study
Diagnosis:
F31.64 – Bipolar disorder, current episode mixed, severe, with psychotic features
Rating Scales: BDRS – The Bipolar Depression Rating Scale: 14
History of Present Illness: 41-year-old female, Hispanic with a previous medical history of Bipolar Disorder, perceptual disturbances, and auditory hallucinations, present to this private office for an initial psychiatric evaluation and follow up after discharge from inpatient hospitalization three days ago. The patient said she complains about her treatment and medications as prescribed by her doctor. The patient said she is not feeling depressed, or having passive death wishes and is not hearing any voices currently. Patient report normal sleep (6-7 hours) and a good appetite. The patient recognized she has a history of poor medication compliance and said she wants a referral to start an outpatient program to help her with her treatment.
Psychiatric History:
The patient was in the hospital for five days after she tried to kill herself by overdose, she was discharged three days ago. The patient state she was hearing voices telling her to kill herself, and she was following the voices. The patient ingests ten pills of clonazepam belongs to her partner. The patient with long psychiatric history with multiple psychiatric admissions. The patient state she has two previous suicidal attempts by overdose and one by jumping in front of a moving car. Patient report PHP 2 years ago. She is not attending any therapy or outpatient program at this time. Assignment Week 9 – NRNP 6635 – Case Study
Substance Abuse History: The patient report a history of substance abuse, alcohol abuse, cocaine abuse, and cannabis abuse since her 20’s. She participated and completed a voluntary rehabilitation program ten years ago, and the patient denies any substance abuse currently. UDS review form previous hospitalization is negative.
Family Psychiatric History:
Patient report that her mother had a history of bipolar disorder and Major Depressive disorder, and she kills herself by overdose when a patient was 12 years old. The patient’s sister has a Depressive Disorder.
Medical/Surgical History: The patient doesn’t have any medical or surgical history.
Medications:
The patient was discharge from impatient hospitalization with the following medications:
Klonopin 0.5mg po bid
Prozac 20mg po qam
Zyprexa 10mg po qhs
1. KLONOPIN
Generic Name: clonazepam
Brand Name: KlonoPIN
Class: Benzodiazepine (anxiolytic, anticonvulsant)
Side Effects: respiratory depression, dependency, abuse, seizures, suicidality, hypotension, orthostatic tachycardia, syncope, blood dyscrasias, hepatomegaly, CNS stimulation.
Patient education: Contact your primary PCP if you feel increased depression, uncommon variations in conduct, or feelings about suicide or hurting yourself; Clonazepam might cause dependence, don’t share your medication with nobody. Keep your medicine in a room or place nobody else can have access; Take the tablet totally, with a full glass of water; do not stop using this medication abruptly, or you might have an unfriendly withdrawal warning sign, as well as seizures (convulsions).
2. PROZAC:
Generic Name: fluoxetine
Brand Names: PROzac, PROzac Weekly, Sarafem
Class: SSRI (Selective serotonin reuptake inhibitor); often classified as an antidepressant.
Side Effects: Nausea, drowsiness, dizziness, anxiety, trouble sleeping, loss of appetite, tiredness, sweating, or yawning may occur.
Patient Education: Share with your PCP all the medications you are taking, including the over the counter medications. Report to your PCP if you have feelings and thoughts of suicide or self-harm. You need to visit your PCP frequently to check your progress. Do not change the dosage or the frequency of this mediation without consulting your doctor. Assignment Week 9 – NRNP 6635 – Case Study
3. ZYPREXA:
Generic Name: olanzapine
Brand Names: ZyPREXA
Class: Atypical antipsychotic (serotonin-dopamine antagonist; second generation; mood stabilizer)
Mechanism of Action: mechanism of action is unknown; antagonizes dopamine, serotonin 5-HT2, and other receptors (thienobenzodiazepine)
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Metabolism: liver extensively; CYP450
Side Effects: Drowsiness, dizziness, lightheadedness, stomach upset, dry mouth, constipation, increased appetite, or weight gain may occur.
Patient Education: Avoid doing activities outdoors, including exercise direct under the sun or high humidity, do not use hot tubs. Drink fluids and dress lightly; stand up slowly when you are in a sitting or lying position; this medication can be taken with or without food. Follow your PCP directions.
Mental Status Exam:
Appearance and behavior: fair hygiene and groomed, cooperative
Eye contact: fair
Level of Alertness: Alert
Mood: euthymic
Affect: congruent
Speech: normal in volume and rate
Thought processes: linear
Thought content: goal-directed
Perceptual disturbances: none report (hx. of Auditory Hallucinations)
Insight/judgment: Good
Suicide ideations/intent/plans: denied
Homicidal ideation/intent/plans: denied.
Points Discussed in Visit: Speaking points with the preceptor
· Medication reconciliation after discharge
· Diagnostic
· Poor medication compliance
· Recommended treatment and therapy
Therapy Recommendations:
The patient is not attending any therapy currently.
The therapy recommended for Bipolar Disorder: Cognitive Behavioral Therapy (CBT) is an individual therapy motivated on the connection between the patient’s mental state, thoughts, and comportments. CBT shows the patient in what way he/she can identify negative thoughts and how to create positive and constructive ways of thinking.
Clinical Impression: 41 years old female Hispanic, with PPHx of bipolar disorder, cocaine abuse, cannabis abuse, and alcohol abuse, appears older than her chronological age. The patient appears clean, with fair eye contact. On exam, the patient is in no distress, calm, cooperative, with a linear, organized thought process. No evidence of psychosis or mania/hypomania. The patient mood is euthymic and affect congruent. The patient reports good energy, appetite, sleep (6-7h nightly), denies any suicidal ideation, and denies perceptual disturbances. She denies racing thoughts. The patient denies current issues with anxiety or panic attacks. The patient doesn’t report any other complaints currently. Assignment Week 9 – NRNP 6635 – Case Study
Diagnosis Code:
F31.64 – Bipolar disorder, current episode mixed, severe, with psychotic features
Treatment Recommendations:
Recommended to the patient to continue with home medications
Patient educated of medication side effects, and benefits of treatment. Patient verbalized understanding. Discussed signs of patient illness and symptom management.
Labs ordered: None at this time – Review of labs results from the previous hospitalization –
Intervention Therapy: The patient recommended to initiate CBT therapy. Practice stress management techniques and incorporate recreational techniques.
The patient referred to the PHP program of Miami Dade County.
The patient instructed to take medication as prescribed. Avoid alcohol. Avoid caffeine and continue with a healthy diet.
The patient instructed to come back for a follow-up consultation in 2 weeks or sooner if needed.
References
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders. DSM-5, Fifth Edition. Arlington, VA, American Psychiatric Association, 2013. (2013)
Stahl, Stephen (2015). Essential Psychopharmacology Prescriber’s Guide. Fifth Edition. New York, NY Cambridge University Press.
NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Exemplar
(The comprehensive evaluation is typically the initial new patient evaluation. You will practice writing this type of note in this course. You will be ruling out other mental illnesses so often you will write up what symptoms are present and what symptoms are not present from illnesses to demonstrate you have indeed assessed for all illnesses which could be impacting your patient. For example, anxiety symptoms, depressive symptoms, bipolar symptoms, psychosis symptoms, substance use, etc.)
CC (chief complaint): A brief statement identifying why the patient is here. This statement is verbatim of the patient’s own words about why presenting for assessment. For a patient with dementia or other cognitive deficits, this statement can be obtained from a family member.
HPI: Begin this section with patient’s initials, age, race, gender, purpose of evaluation, current medication and referral reason. For example:
N.M. is a 34-year-old Asian male presents for psychiatric evaluation for anxiety. He is currently prescribed sertraline which he finds ineffective. His PCP referred him for evaluation and treatment.
Or
P.H., a 16-year-old Hispanic female, presents for psychiatric evaluation for concentration difficulty. She is not currently prescribed psychotropic medications. She is referred by her therapist for medication evaluation and treatment. Assignment Week 9 – NRNP 6635 – Case Study
Then, this section continues with the symptom analysis for your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis.
Paint a picture of what is wrong with the patient. This section contains the symptoms that is bringing the patient into your office. The symptoms onset, duration, frequency, severity, and impact. Your description here will guide your differential diagnoses. You are seeking symptoms that may align with many DSM-5 diagnoses, narrowing to what aligns with diagnostic criteria for mental health and substance use disorders.
Past Psychiatric History: This section documents the patient’s past treatments. Use the mnemonic Go Cha MP.
General Statement: Typically, this is a statement of the patients first treatment experience. For example: The patient entered treatment at the age of 10 with counseling for depression during her parents’ divorce. OR The patient entered treatment for detox at age 26 after abusing alcohol since age 13.
Caregivers are listed if applicable.
Hospitalizations: How many hospitalizations? When and where was last hospitalization? How many detox? How many residential treatments? When and where was last detox/residential treatment? Any history of suicidal or homicidal behaviors? Any history of self-harm behaviors?
Medication trials: What are the previous psychotropic medications the patient has tried and what was their reaction? Effective, Not Effective, Adverse Reaction? Some examples: Haloperidol (dystonic reaction), risperidone (hyperprolactinemia), olanzapine (effective, insurance wouldn’t pay for it)
Psychotherapy or Previous Psychiatric Diagnosis: This section can be completed one of two ways depending on what you want to capture to support the evaluation. First, does the patient know what type? Did they find psychotherapy helpful or not? Why? Second, what are the previous diagnosis for the client noted from previous treatments and other providers. Thirdly, you could document both.
Substance Use History: This section contains any history or current use of caffeine, nicotine, illicit substance (including marijuana), and alcohol. Include the daily amount of use and last known use. Include type of use such as inhales, snorts, IV, etc. Include any histories of withdrawal complications from tremors, Delirium Tremens, or seizures.
Family Psychiatric/Substance Use History: This section contains any family history of psychiatric illness, substance use illnesses, and family suicides. You may choose to use a genogram to depict this information. Be sure to include a reader’s key to your genogram or write up in narrative form.
Social History: This section may be lengthy if completing an evaluation for psychotherapy or shorter if completing an evaluation for psychopharmacology. However, at a minimum, please include:
Where patient was born, who raised the patient
Number of brothers/sisters (what order is the patient within siblings)
Who the patient currently lives with in a home? Are they single, married, divorced, widowed? How many children?
Educational Level
Hobbies:
Work History: currently working/profession, disabled, unemployed, retired?
Legal history: past hx, any current issues?
Trauma history: Any childhood or adult history of trauma?
Violence Hx: Concern or issues about safety (personal, home, community, sexual (current & historical) Assignment Week 9 – NRNP 6635 – Case Study
Medical History: This section contains any illnesses, surgeries, include any hx of seizures, head injuries.
Current Medications: Include dosage, frequency, length of time used, and reason for use. Also include OTC or homeopathic products.
Allergies: Include medication, food, and environmental allergies separately. Provide a description of what the allergy is (e.g., angioedema, anaphylaxis). This will help determine a true reaction vs. intolerance.
Reproductive Hx: Menstrual history (date of LMP), Pregnant (yes or no), Nursing/lactating (yes or no), contraceptive use (method used), types of intercourse: oral, anal, vaginal, other, any sexual concerns
ROS: Cover all body systems that may help you include or rule out a differential diagnosis. Please note: THIS IS DIFFERENT from a physical examination!
You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.
Example of Complete ROS:
GENERAL: No weight loss, fever, chills, weakness, or fatigue.
HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.
RESPIRATORY: No shortness of breath, cough, or sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.
GENITOURINARY: Burning on urination, urgency, hesitancy, odor, odd color
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness.
HEMATOLOGIC: No anemia, bleeding, or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.
Physical exam (If applicable and if you have opportunity to perform—document if exam is completed by PCP): From head to toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head-to-toe format i.e., General: Head: EENT: etc.
Diagnostic results: Include any labs, X-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines).
Assessment
Mental Status Examination: For the purposes of your courses, this section must be presented in paragraph form and not use of a checklist! This section you will describe the patient’s appearance, attitude, behavior, mood and affect, speech, thought processes, thought content, perceptions (hallucinations, pseudohallucinations, illusions, etc.)., cognition, insight, judgment, and SI/HI. See an example below. You will modify to include the specifics for your patient on the above elements—DO NOT just copy the example. You may use a preceptor’s way of organizing the information if the MSE is in paragraph form. Assignment Week 9 – NRNP 6635 – Case Study
He is an 8-year-old African American male who looks his stated age. He is cooperative with examiner. He is neatly groomed and clean, dressed appropriately. There is no evidence of any abnormal motor activity. His speech is clear, coherent, normal in volume and tone. His thought process is goal directed and logical. There is no evidence of looseness of association or flight of ideas. His mood is euthymic, and his affect appropriate to his mood. He was smiling at times in an appropriate manner. He denies any auditory or visual hallucinations. There is no evidence of any delusional thinking. He denies any current suicidal or homicidal ideation. Cognitively, he is alert and oriented. His recent and remote memory is intact. His concentration is good. His insight is good.
Differential Diagnoses: You must have at least three differentials with supporting evidence. Explain what rules each differential in or out and justify your primary diagnosis selection. Include pertinent positives and pertinent negatives for the specific patient case.
Also included in this section is the reflection. Reflect on this case and discuss whether or not you agree with your preceptor’s assessment and diagnostic impression of the patient and why or why not. What did you learn from this case? What would you do differently?
Also include in your reflection a discussion related to legal/ethical considerations (demonstrating critical thinking beyond confidentiality and consent for treatment!), health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).
References
You are required to include at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines which relate to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting. Assignment Week 9 – NRNP 6635 – Case Study
