Case Study

COMPLEX CASE STUDY PRESENTATION
Instructions:

· State 3–4 objectives for the presentation that are targeted, clear, use appropriate verbs from Bloom’s taxonomy, and address what the audience will know or be able to do after viewing.

· See case study below.

· Present the full complex case study. Use the attached document to complete the assignment. Include chief complaint; history of present illness; any pertinent past psychiatric, substance use, medical, social, family history; most recent mental status exam; current psychiatric diagnosis including differentials that were ruled out; and plan for treatment and management.

· 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.

· Pose three questions or discussion prompts, based on your presentation, that your colleagues can respond to after reading your study presentation.

· Specifically address the following for the patient, using your SOAP note as a guide.

· Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life?

· Objective: What observations did you make during the psychiatric assessment?

· Assessment: Discuss their mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses and why you chose them. List them from highest priority to lowest priority. What was your primary diagnosis, and why? Describe how your primary diagnosis aligns with DSM-5-TR diagnostic criteria and is supported by the patient’s symptoms.

Important

· Plan: What was your plan for psychotherapy (include one health promotion activity and patient education)? What was your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan. Discuss an identified social determinate of health impacting this patient’s mental health status and provide your recommendation for a referral to assist this patient in meeting this identified need (students will need to conduct research on this topic both in the literature and for community resources).

Important

· Reflection notes: What would you do differently with this patient if you could conduct the session again? If you are able to follow up with your patient, explain whether these interventions were successful and why or why not. If you were not able to conduct a follow-up, discuss what your next intervention would be.

· At least 5 references

· APA 7

· Use the template to complete the assignment

· Review the attached PDF example from a previous course as a guide for this assignment,

· Remember to include the objectives and 3 questions for my peer to answers.

Case Study

Psych Chief Complain–MDD

Reason for Admission in Patient’s Own Words: “I feel like I’m confused, I think my new meds are making me sick.”

HPI / Subjective

Patient is a 67-year-old white Hispanic male with a PPHx of Depression and anxiety and PMHx bilateral lower extremity edema who presented to our clinic as a follow up after D/C from Crisis 2 weeks ago accompanied by Adult Living Facility (ALF) Administrator. Today patient was found to be AAO x 3, in NAD, calm, Cooperative. Patient was noted to be disorganized, tangential, having difficulty concentrating, acting bizarre and unfocused. Patient reported his mood as “I’m just so confused, and I don’t know what’s really happening with me” with congruent dysthymic affect. When asked why they came to the clinic, patient stated “I was sent here from Fellowship house because I wasn’t eating as much as I used to. My appetite has gone. I think the new medications I’m taking are not good for me.” Patient reported he was discharged one week ago from Westchester hospital on a new medication regimen which he felt was helping him sleep better and improve his depression but was not letting him think clearly and was taking away his appetite. Patient referred he had been depressed a few weeks prior to last admission and has since felt that these medications are not helping him overall. Patient endorsed symptoms of depression including excessive sleep, loss of interest, feelings of guilt, low energy, difficulty concentrating, poor appetite, irritability, and psychomotor retardation. Patient denied symptoms of mania including increased energy, elevated mood, grandiosity, and distractibility, decreased need for sleep, impulsivity, and flights of ideas, talkativeness, and increase in goal-oriented activities. Patient denied perceptual disturbances including auditory or visual hallucinations. Patient denied any suicidal ideas, intentions, or plans. Patient denied any homicidal ideas, intentions, or plans. Past Psychiatric History: Patient endorsed multiple previous admissions to various psychiatric hospitals. Patient referred last admission was for approximately 5 days at Westchester hospital and was discharged with his current home medications. In addition to this, patient takes marijuana daily. Patient denied any history of Long-Acting Injections or state hospital admissions. Patient referred a “remote” history of suicide attempts in the past. Substance use History: Patient denied any tobacco or alcohol use. Patient denied any history of intentional or unintentional overdose, rehab admissions, or problems with addiction. Positive for marijuana Family Psychiatric History: Patient denied any family history of psychiatric diagnosis or treatments. Patient denied any family history of completed or attempted suicide. Patient denied any family history of substance use issues, state hospital admissions, psychotropic medications, LAI, ECT, or rehab admissions. Collateral information: Adult Living Facility, Administrator Collateral referred since discharge one week ago patient has been improving however has been noted to be acting bizarre. Collateral refers patient only eating 1 or 2 meals per day, is self-withdrawn, sleeps more, and has been less interactive with staff and other members of the ALF. Collateral stated patient has been complaint with his medications and has been attending Fellowship House Regularly.

Past Medical History

Abdominal pain

Alcoholism, the patient denies current alcohol abuse

Depressive disorder

Hypertension

Home Medications

chlorproMAZINE HCl Oral Tablet 200 MG Dose: 200 MG BY MOUTH AT BEDTIME

Furosemide Oral Tablet 20 MG Dose: 20 MG BY MOUTH DAILY IN THE MORNING

OXcarbazepine Oral Tablet 150 MG Dose: 150 MG BY MOUTH THREE TIMES A DAY

Potassium Chloride ER Oral Tablet Extended Release 20 MEQ Dose: 20 MEQ BY MOUTH DAILY IN THE MORNING

QUEtiapine Fumarate Oral Tablet 400 MG Dose: 400 MG BY MOUTH AT BEDTIME

Allergies

No Known Allergies

Marital status

Divorce, 2 adult sons, living outstate

Family History

parents

Father Deceased

Alcoholism, MI

Mother Deceased Cerebrovascular accident @ 53

Alcoholism

Mental Status Exam

Orientation

Awake, Alert, Oriented to person, time and place, Oriented to time, Oriented to place, Oriented to person

Appearance

Looks older, Wearing Casual Clothing

Manner/Rapport/Approach

Evasive

Hygiene

Poor

Speech

Normal Rate, Normal Volume

Eye Contact

Fair

Posture/Gait

Posture normal, Gait normal

Abnormal Movements

None (None)

Mood

Dysthymia

Affect

Congruent

Thought Processing

Loosening of associations, Disorganized

Thought Content

Catastrophizing, Helplessness, Hopelessness, Obsessional thoughts, Paranoid delusions

Hallucinations

None

Suicidal Ideation

Denies idea, intention and plan

Homicidal Ideation

Denies

Insight

Poor or Impaired

Judgement

Poor or Impaired

Memory

Imparied Recent (5 minutes), Remote, Immediate

Approximate Intelligence

Above average or Normal

Receptive Language

Able to comprehend questions

Basic Calculations

Intact

Intact

DSM V DIAGNOSIS

Primary Diagnosis

Major Depressive Disorder, recurrent, severe without psychotic features F33.2

Catatonia

Not Present

Additional Specifiers

Moderate anxiety

Abnormal Psychomotor Behavior

Not Present

Delusions

Equivocal

Depression

Severe

Disorganized Speech

Mild

Hallucinations

Not Present

Impaired Cognition

Not Present

Mania

Not Present

The clinician provided psychoeducation to clarify areas of difficulty. The clinician provided support and structure. Psychoeducation was provided regarding medication compliance, and the patient was receptive. The patient was encouraged to continue follow-up psychotherapy to monitor his symptoms. Individual psychotherapy is scheduled in two weeks.