Case Study WEEK 7: M. Robinson

Posted on: 28th May 2023

Question

Client is being seen for the first time with this organization. Client has a hx of anxiety and depression that dates back to 2018. At the time she was being treated by her PCP WITH LEXAPRO, wellbutrin, and xanax. She says after about 3 months, she stopped using the medication because she felt like it did not work. She says in 2019, she was involved in a volatile domestic relationship that included physical, emotional, and verbal abuse. She says in August 2021, her son was murdered. She says initially she was having auditory hallucinations, but since then endorses racing thoughts, insomnia, waking up feeling tired, irritability, sporadic eating without any significant weight changes, isolating, excessive crying, and poor focus/concentration. Denies si/hi and a/v hallucinations. Admits to drinking about 4 ounces of liquor daily. Denies any on-going medical problems, illicit drug usage, tobacco usage, and medication allergies.

Objective

Mental Status Exam

Orientation: Person, place, and time

Appearance: Neat hygiene and appearance

Behavior/Attitude: Pleasant, cooperative, guarded, paranoid, restless, anxious, withdrawn, disorganized, avoidant, resistant

Speech: Normal rate and rhythm; easily understandable, poverty of speech, pressured, rapid, loud, soft

Thought Process: No obsessions, preoccupations, or phobia noted; No si/hi; no delusions or ideas of reference; paranoid, delusional, bizarre, obsessive, grandiose

Mood: Euthymic, neutral, dysphoric, depressed, apathetic, anxious, elated, ecstatic, hypomanic, manic

Affect: Appropriate, Inappropriate, broad, constricted, euthymic, dysphoric, depressed, reactive, exagerated

Memory: Intact immediate, intact remote

Concentration: Intact, attentive, distracted, inattentive, confused

Insight: Good, fair, poor

Judgment: Intact, fair, impaired, poses imminent potential threat to others/self

Assessment

Diagnoses attached to this encounter:

(F33.1) Major depressive disorder, recurrent, moderate

(F41.1) Generalized anxiety disorder

(F43.12) Post-traumatic stress disorder, chronic

Plan

Referred to therapy

Started on vraylar 1.5mg and klonopin 0.5mg qam and 1mg qhs

Medication education given

RTC in 2 weeks

Educated on etoh being a depressant and sleep hygiene

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?

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) possible diagnoses. List them from highest to lowest priority. What was your primary diagnosis and why?

Reflection notes: What would you do differently in a similar patient evaluation? Reflect on one social determinant of health according to the HealthyPeople 2030 (you will need to research) as applied to this case in the realm of psychiatry and mental health. As a future advanced provider, what are one health promotion activity and one patient education consideration for this patient for improving health disparities and inequities in the realm of psychiatry and mental health? Demonstrate your critical thinking.

Description of chief complaint and history of present illness--

Excellent 5 (5%) - 5 (5%)

The student provides an accurate, clear, and complete description of the chief complaint and history of present illness.

Good 4 (4%) - 4 (4%)

The student provides an accurate description of the chief complaint and history of present illness.

Fair 2 (2%) - 3 (3%)

The student provides a vague, inaccurate, or incomplete description of the chief complaint and history of present illness, or description is missing.

Poor 0 (0%) - 1 (1%)

The student provides a completely inaccurate, or incomplete description of the chief complaint and history of present illness, or the description is missing.

Description of past psychiatric, substance use, medical, social, and family history--

Excellent 5 (5%) - 5 (5%)

The student provides an accurate, clear, and complete description of past psychiatric, substance use, medical, social, and family history.

Good 4 (4%) - 4 (4%)

The student provides an accurate description of past psychiatric, substance use, medical, social, and family history.

Fair 2 (2%) - 3 (3%)

The student provides a vague, inaccurate, or incomplete description of psychiatric, substance use, medical, social, and family history, or description is missing.

Poor 0 (0%) - 1 (1%)

The student provides a completely inaccurate, or incomplete description of psychiatric, substance use, medical, social, and family history, or description is missing.

Discussion of most recent mental status exam and observations made during interview and review of systems--

Excellent 14 (14%) - 15 (15%)

The student provides an accurate, clear, and complete discussion of results from most recent mental status exam and observations made during interview and review of systems.

Good 12 (12%) - 13 (13%)

The student provides an accurate discussion of results from most recent mental status exam and observations made during interview and review of systems.

Fair 11 (11%) - 11 (11%)

The student provides a vague, inaccurate, or incomplete discussion of results from most recent mental status exam and observations made during interview and review of systems.

Poor 0 (0%) - 10 (10%)

All or most of the discussion is inaccurate or missing.

Discussion of diagnostics with results--

Excellent 9 (9%) - 10 (10%)

The student provides an accurate, clear, and complete discussion of diagnostics with results.

Good 8 (8%) - 8 (8%)

The student provides an accurate discussion of diagnostics with results.

Fair 7 (7%) - 7 (7%)

The student provides a vague, inaccurate, or incomplete discussion of diagnostics with results.

Poor 0 (0%) - 6 (6%)

All or most of the discussion is inaccurate or missing.

Diagnostic Impression with three (3) differential diagnoses

Reflection on this case--

Excellent 23 (23%) - 25 (25%)

The student provides an accurate, clear, and complete diagnostic impression with three (3) differentials.

Reflections are thorough, thoughtful, and demonstrate critical thinking.

Reflections contain all 3 elements from the assignment directions.

Good 20 (20%) - 22 (22%)

The student provides an accurate diagnostic impression with three (3) differentials.

Reflections demonstrate critical thinking.

Reflections contain 2 of the elements from the assignment directions.

Fair 18 (18%) - 19 (19%)

The student provides a vague, inaccurate, less than 3, or incomplete diagnostic impression with differentials.

Reflections are somewhat general or do not demonstrate critical thinking.

Reflections contain 1 of the required elements from the assignment directions.

Poor 0 (0%) - 17 (17%)

All or most of the discussion is inaccurate or missing. No diagnostic impression and less than 2 differential diagnoses.

Reflections are incomplete, inaccurate, or missing.

There are no Reflections elements from the assignment directions.

Comprehensive Psychiatric Evaluation documentation--

Excellent 23 (23%) - 25 (25%)

The response clearly, accurately, and thoroughly follows the Comprehensive Psychiatric Evaluation format to document the selected patient case.

Good 20 (20%) - 22 (22%)

The response accurately follows the Comprehensive Psychiatric Evaluation format to document the selected patient case.

Fair 18 (18%) - 19 (19%)

The response follows the Comprehensive Psychiatric Evaluation format to document the selected patient case, with some vagueness and inaccuracy.

Poor 0 (0%) - 17 (17%)

The response incompletely and inaccurately follows the Comprehensive Psychiatric Evaluation format to document the selected patient case.

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Solution

Case Study WEEK 7: M. Robinson

Subjective

The client’s primary complaint is that she has anxiety and depression. She claims that she has been experiencing these symptoms since 2018 and that they have worsened after her son was killed in August of the same year. She recommends experiencing racing thoughts, restless sleep, impatience, and lack of focus or attention. She claims to have no hallucinations or suicidal or violent thoughts. In addition to anxiety and sadness in 2018, the patient also had a turbulent domestic relationship in 2019 that involved verbal, emotional, and physical violence. The patient has a history of using Xanax, Wellbutrin, and Lexapro and experiencing auditory hallucinations and frenzied thoughts following her son’s death in August 2021. The patient disavows having any ongoing health issues, using illegal substances, smoking, or having any prescription allergies. Some of the client’s troubling symptoms are anxiety, sadness, auditory hallucinations, racing thoughts, sleeplessness, irritability, poor focus/concentration, and frequent sobbing. Through their experiences of racing thoughts, sleeplessness, irritability, poor focus/concentration, and isolation, the client’s symptoms are affecting how they can perform. The client finds it challenging to manage these symptoms in their daily lives.

Objective

Diagnostic results presenting the history of the prevailing condition

The client said during the interview that she had experienced anxiety and despair since 2018. She stated that she was being treated with Lexapro, Wellbutrin, and Xanax at the time, but she stopped taking medicine after three months because she thought it was ineffective. The client additionally disclosed that in 2019, they were a part of a turbulent domestic situation that included verbal, emotional, and physical assault. The client’s kid was murdered in August 2021, and she started having auditory hallucinations. Since then, she has endorsed racing thoughts, sleeplessness, feeling exhausted upon awakening, anger, irregular eating without noticeably changing weight, isolation, frequent sobbing, and lack of attention and concentration (Ströhle et al., 2018). The individual denied having any ongoing health issues, using illegal substances, smoking, or having any sensitivities to medications.

Assessment

The client receives orientation to time, location, and people. She thinks logically and with clarity. She can give a succinct and precise summary of her past. She has sound judgment and understanding. She can explain her present symptoms in plain and simple terms. She experiences all the human emotions. She cooperates during the interview and is always agreeable. There are no indications of psychosis in her.

Differential diagnoses and rationale

1. Major depressive disorder, recurrent, moderate - due to the client’s history of depression and the current symptoms she is experiencing.

2. Generalized anxiety disorder - due to the client’s history of anxiety and the current symptoms she is experiencing.

3. Post-traumatic stress disorder, chronic - due to the client’s history of trauma and the current symptoms she is experiencing.

What has to be changed?

Different approaches should be employed in various circumstances. Understanding the client’s background in detail is the first step. Unfortunately, the perfect reason for the client’s lack of adherence and stoppage of taking the prescribed medication is not provided. Additionally, the domestic situation in 2019 is not elaborated on effectively. It is possible that the domestic situation was an aggravating factor in their mind which can also be why the client stopped attending to the prescribed medication. Having detailed information about the client’s history will make it easier to find appropriate answers and confirm the presented hypothesis, effectively providing additional treatment to help improve the client’s condition.

The second concern that needs to be done differently is assessing the client’s mental system. Based on the information provided about the client’s mental state, the client currently experiences hallucinations and delusions. Therefore, the client’s mental state needs to be properly assessed to ensure that there are no delusions or hallucinations. Additionally, assessing the client’s alcohol intake is critical. The rationale behind the assessment of alcohol intake assessment is to manage the intake and reduce the depressive and anxiety symptoms that are all associated with uncontrolled and excessive alcohol consumption. Lastly, it is also vital to ensure that the client does not engage in the intake of any illicit drugs. Prevention of illicit indulgence reduces the risks of anxiety, depression, or even domestic violence provided to the client. HealthyPeople 2030’s definition of social determinants of health (study needed) applies to this situation in the psychotherapy and psychological health fields.

Economic stability is one of the social determinants of health applicable to the presented case. Being economically stable is an insinuation of having all the needed resources for a healthy life (Islam, 2019). An economically stale individual can access health facilities without struggle, attend the best education, and access all the leisure without struggle. According to the data in the research study, the client’s anxiety and sadness may be adequately explained by economic instability. According to the information provided about the client, the client has a history of anxiety and depression that can be traced back to 2018 when she was being treated using Lexapro, Wellbutrin, and Xanax. The client, however, stopped because she felt it was not working out and could not receive further treatment due to economic strain (Islam, 2019). She was a part of a turbulent domestic situation in 2019 that included verbal, emotional, and physical assault. Since the outset, she has experienced various symptoms, including racing thinking, sleep problems, a sense of exhaustion when she wakes up, anger, intermittent eating without appreciably affecting her weight, social isolation, distress, and trouble concentrating. Initially, she claims she was experiencing auditory hallucinations. Therefore, the client’s economic strain is a social focus affecting her psychiatry and mental realm.

Future Healthcare Consideration and Education Consideration for the Client

For this patient, the health promotion activity may center on assisting her in creating a support network. This can entail giving her information about support groups and contacting neighborhood resources and social agencies (Lu et al., 2020). In addition, the healthcare professional could advise the patient to engage in relaxation and self-care practices like yoga or meditation. From the case study, the patient seems to be living a solitary life, especially after the death of her child. Therefore, creating a support network will assist in empathetic strategies to improve her depression and anxiety.

Educating the patient on the causes and management strategies for the patient’s healthcare consideration. Patient education entails informing the patients of their medical issues and the predisposing factors to their prevailing condition (Yen & Leasure, 2019). Patient education also instills knowledge into the patients over the dos and the don’ts as far as their health is concerned. It’s crucial to tell the patient about her mental health concerns and available treatments as part of patient education. Additionally, it’s critical to inform the patient of the warning signs and symptoms of mental health issues and how to get assistance if she encounters a crisis (Yen & Leasure, 2019). For the patient provided within the case study, the patient needs to be told about the non-pharmacological interventions for managing anxiety disorder and depression. The patient should also get education regarding the significance of taking prescribed drugs and the repercussions of doing otherwise.

References

Islam, M. M. (2019). Social Determinants of Health and Related Inequalities: Confusion and Implications. Frontiers in Public Health, 7(11). https://doi.org/10.3389/fpubh.2019.00011

Lu, Y., Luo, S., & Liu, X. (2020). How do patients with depression develop social support networks through online health communities? A social network analysis from an online depression community (Preprint). JMIR Medical Informatics. https://doi.org/10.2196/24618

Ströhle, A., Gensichen, J., & Domschke, K. (2018). The Diagnosis and Treatment of Anxiety Disorders. Deutsches Aerzteblatt Online, 115(37). https://doi.org/10.3238/arztebl.2018.0611

Yen, P. H., & Leasure, A. R. (2019). Use and effectiveness of the teach-back method in patient education and health outcomes. Federal Practitioner, 36(6), 284–289. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6590951/

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