case study 8: | Nursing

Clinical Requirement:

NRNPPRAC6635ComprehensivePsychiatricEvaluationTemplate.docx NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template Week (enter week #): (Enter assignment title) Student Name College of Nursing-PMHNP, Walden University NRNP 6635: Psychopathology and Diagnostic Reasoning Faculty Name Assignment Due Date Subjective: CC (chief complaint): HPI: Past Psychiatric History: · General Statement: · Caregivers (if applicable): · Hospitalizations: · Medication trials: · Psychotherapy or Previous Psychiatric Diagnosis: Substance Current Use and History: Family Psychiatric/Substance Use History: Psychosocial History: Medical History: · Current Medications: · Allergies: · Reproductive Hx: ROS: · GENERAL: · HEENT: · SKIN: · CARDIOVASCULAR: · RESPIRATORY: · GASTROINTESTINAL: · GENITOURINARY: · NEUROLOGICAL: · MUSCULOSKELETAL: · HEMATOLOGIC: · LYMPHATICS: · ENDOCRINOLOGIC: Objective: Physical exam: if applicable Diagnostic results: Assessment: Mental Status Examination: Differential Diagnoses: Reflections: References © 2021 Walden University Page 1 of 3 CaseStudy8.docx Training Title 151 Name: Daniela Petrov Gender: female Age:47 years old T- 98.8 P- 84 R 20 B/P 132/90 Ht 5’8 Wt 128lbs Background: Moved to Everett, Washington from Russia with her parents when she was 16 years old. Currently lives in Boise, Idaho. She has younger 1 brother, 3 older sisters. Denied family mental health or substance use issues. No history of inpatient detox or rehab denied self-harm hx;Menses regular. uses condoms for birth control Has fibromyalgia. She works part time cashier at Save A Lot Grocery Store. Dropped out of high school in 10th grade. Sleeps 5-6 hours on average, appetite good. Use the attached Template: A.Create documentation in the Comprehensive Psychiatric Evaluation Template about the patient you selected. In the Subjective section, provide: • Chief complaint• History of present illness (HPI)• Past psychiatric history• Medication trials and current medications• Psychotherapy or previous psychiatric diagnosis• Pertinent substance use, family psychiatric/substance use, social, and medical history• Allergies• ROS B.In the Objective section, provide:• Physical exam documentation of systems pertinent to the chief complaint, HPI, and history• Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses. C. In the Assessment section, provide:• Results of the mental status examination, presented in paragraph form.• At least three differentials with supporting evidence. List them from top priority to least priority. Compare the DSM-5-TR diagnostic criteria for each differential diagnosis and explain what DSM-5-TR criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case. · Consider what history would be necessary to collect from this patient. · Consider what interview questions you would need to ask this patient. · Identify at least three possible differential diagnoses for the patient. D.Reflect on this case. Discuss what you learned and what you might do differently. Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), social determinates of health, 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.). E. Provide at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support your diagnostics and differential diagnoses. Be sure they are current (no more than 5 years old). · American Psychiatric Association. (2022). Substance related and addictive disorders. In  Diagnostic and statistical manual of mental disordersLinks to an external site.  (5th ed., text rev.). https://go.openathens.net/redirector/waldenu.edu?url= https://dsm.psychiatryonline.org/doi/full/10.1176/appi.books.9780890425787.x16_Substance_Related_Disorders · Boland, R. & Verduin, M. L. & Ruiz, P. (2022).  Kaplan & Sadock’s synopsis of psychiatry (12th ed.). Wolters Kluwer. · Chapter 4, “Substance Use and Addictive Disorders” · Chapter 2 only section 2.17, “Adolescent Substance Abuse” · Chapter 27 “Ethics and Professionalism” · Chapter 28 “Forensic and Legal Issues” Video Transcript: https://video.alexanderstreet.com/p/nROXPVlRl Top of Form Search transcript Bottom of Form 00:00:00TRANSCRIPT OF VIDEO FILE:  00:00:00_____________________________________________________________________  00:00:00BEGIN TRANSCRIPT:  00:00:00DISCLAIMER  00:00:00THE INFORMATION CONTAINED HEREIN IS OF A GENERAL NATURE AND CANNOT SUBSTITUTE FOR THE ADVICE OF A MEDICAL PROFESSIONAL. THE CONTENT PROVIDED MAY NOT APPLY TO YOU OR YOUR SYMPTOMS. YOU SHOULD NOT RELY ON THIS INFORMATION AS A SUBSTITUTE FOR. NOR DO THEY REPLACE, PROFESSIONAL MEDICAL ADVICE, DIAGNOSIS OR TREATMENT. IF YOU HAVE ANY CONCERNS OR QUESTIONS ABOUT YOUR HEALTH OR THE CONTENT. YOU SHOULD ALWAYS CONSULT WITH A PHYSICIAN OR OTHER HEALTH CARE PROFESSIONAL. DO NOT DISREGARD. AVOID OR DELAY OBTAINING MEDICAL OR HEALTH RELATED ADVICE FROM YOUR HEALTH-CARE PROFESSIONAL. THE CONTENT SHOULD NOT BE USED IN PLACE OF A CALL OR VISIT TO A MEDICAL. HEALTH OR OTHER COMPETENT PROFESSIONAL. WHO SHOULD BE CONSULTED BEFORE ADOPTING ANY OF THE SUGGESTIONS IN THE CONTENT OR DRAWING INFERENCES FROM IT.  00:00:05SYMPTOM MEDIA. LLC DISCLAIMS ALL RESPONSIBILITY FOR ANY LIABILITY LOSS OR RISK. PERSONAL OR OTHERWISE. WHICH IS INCURRED AS A CONSEQUENCE. DIRECTLY OR INDIRECTLY. OF THE USE AND APPLICATION OF ANY OF THE CONTENT CONTAINED HEREIN.  00:00:10[sil.]  00:00:15UNKNOWN I see in your chart that you asked your family physician to prescribe oxycodone for your elbow pain, and that your family physician is worried that some of other medications, drugs you may use may interact with the oxycodone?  00:00:35UNKNOWN Oxycodone is that’s the same as OxyContin?  00:00:40UNKNOWN Oh, yeah, yeah. Oxycodone is the generic name.  00:00:45UNKNOWN Yeah, I did ask for OxyContin, but I don’t take any other medications or drugs. So I’m kind of opposed to putting anything unhealthy in my body.  00:00:55UNKNOWN Okay. So what else have you tried?  00:01:00UNKNOWN Nothing else works.  00:01:00UNKNOWN Ibuprofen, acetaminophen?  00:01:00UNKNOWN Not even close.  00:01:05UNKNOWN No?  00:01:05UNKNOWN Yeah. I mean, I’m allergic to codeine.  00:01:05UNKNOWN Allergic?  00:01:10UNKNOWN Yeah, like in Tylenol 3. A little while back, my friend was in a motorcycle accident and had some leftover, and I tried one of those, and I was way allergic.  00:01:20UNKNOWN What was the allergic response you had?  00:01:25UNKNOWN My face flushed like real bad, besides it didn’t work.  00:01:30UNKNOWN Have you tried morphine?  00:01:30UNKNOWN Well, that’s, that’s addictive, isn’t it?  00:01:35UNKNOWN Yeah, well all the pain medications or most of them are addictive. Anti-inflammatory medications are not usually addictive.  00:01:45UNKNOWN Yeah, I tried morphine and the codeine, didn’t work. Yeah. I get headaches too. So ideally I need something that works for both. You know, I’d rather not take two medications if I don’t have to, you know. Less medications the better, that’s what grandma always said.  00:02:05UNKNOWN Grandma? Okay.  00:02:05UNKNOWN Yeah.  00:02:10UNKNOWN Did you… Have you ever tried Dilaudid?  00:02:15UNKNOWN Yeah. Yeah. They gave that to me in the ER once, but just made me dizzy and constipated. Constipated for like a month.  00:02:20UNKNOWN Oh, wow.  00:02:25UNKNOWN Yeah. Yeah. I almost had to go back to the hospital for constipation. Can you imagine having to go to the hospital for constipation?  00:02:30UNKNOWN Oh, my goodness.  00:02:30UNKNOWN Yeah, that’s how bad it was.  00:02:30UNKNOWN Have you tried Demerol?  00:02:35UNKNOWN Yeah, it kind of worked for my headache. It comes in a shot, right?  00:02:45UNKNOWN Yeah. An injection.  00:02:45UNKNOWN Yeah, yeah, they gave that to me at the hospital. But that’s the thing, you know, you can only get it at the hospital, so it’s not like it’s going to work for me every day. And it didn’t do anything for my elbow. So, uh… OxyContin, it’s the only thing that works for both. The only thing that works for both.  00:03:00UNKNOWN You do seem set on the oxycodone?  00:03:00UNKNOWN Because it works.  00:03:05UNKNOWN What else have you tried other than medications?  00:03:10UNKNOWN Other than medications?  00:03:10UNKNOWN Yeah.  00:03:10UNKNOWN Yoga.  00:03:10UNKNOWN Okay.  00:03:15UNKNOWN Yeah. Tried that. Other kinds of meditation. I mean, that’s the thing with meditation is, it works while you’re doing it, but then as soon as you stop, zilch. You know, biofeedback.  00:03:30UNKNOWN Good.  00:03:30UNKNOWN One doc tried that, same thing. You know works while you’re doing it, but then when you stop doesn’t help at all. What else? Like warm, hot compresses, candles, long walks on the beach, massages.  00:03:50UNKNOWN Wow.  00:03:50UNKNOWN And my boyfriend is really good at massages actually. He’s studied with this guru in India.  00:03:55UNKNOWN Oh, wow.  00:03:55UNKNOWN Yeah, swear to God.  00:04:00UNKNOWN You have tried a lot of solutions. Let me ask you more about your medication history.  00:04:05UNKNOWN I mean, I only take stuff for my headache and my elbow.  00:04:10UNKNOWN Okay.  00:04:10UNKNOWN Yeah. I don’t… Like I said, you know, I don’t like putting unhealthy things in my body. Vitamins, I take vitamins.  00:04:20UNKNOWN Yeah? Okay.  00:04:20UNKNOWN Like fish oils, some supplements, but nothing corporate, nothing pharmaceutical. You know, I don’t… I don’t want to put that in me. You know, I mean, even coming here today, you know, asking for this, it goes against my values.  00:04:35UNKNOWN I see. Okay.  00:04:35UNKNOWN But I got to function.  00:04:40UNKNOWN Do you drink alcohol?  00:04:40UNKNOWN On, I don’t know, like special occasions, you know, like weddings, funerals, birthdays. I got a ton of friends, so, you know, whenever we have a birthday we’re going to drink. Let me think, like holidays, New Years, and Christmases. There’s Christmas and then we also celebrate Russian Orthodox Christmas on January 7th.  00:05:10UNKNOWN So how often on the average?  00:05:15UNKNOWN Oh, I don’t know. When you add it all up, once, maybe twice a week, I guess.  00:05:20UNKNOWN And will you drink enough to get intoxicated?  00:05:20UNKNOWN Depends on who I’m drinking with. As Zane, that’s my boyfriend, he drinks a lot, so I drink a little more when I’m with him.  00:05:35UNKNOWN Any legal problems from the drinking?  00:05:35UNKNOWN Once. So dumb. Yeah, just one little charge for drinking. I was like the tiniest little bit over the limit. So, yeah, I got that and I had to take that course, that like stupid, boring course. But I learned my lesson. You know, if you’re a little bit over the limit, stick to the back roads.  00:06:00UNKNOWN So you will still drive?  00:06:00UNKNOWN Well, yeah, but I’m super careful.  00:06:00UNKNOWN You think after you’ve been drinking, that’s an okay idea to drive?  00:06:05UNKNOWN It’s better than letting Zano drive.  00:06:10UNKNOWN Zano?  00:06:10UNKNOWN Zane, Zano, same person. Yeah. I mean, he doesn’t even have his license anymore. Not that it stops him.  00:06:20UNKNOWN Oh. What about marijuana?  00:06:20UNKNOWN Do I use it?  00:06:25UNKNOWN Yeah.  00:06:25UNKNOWN Marijuana medically helps with my headaches, so, yeah, I use it. Yeah. It’s my right. Yeah, it’s your right. It’s everybody’s right.  00:06:40UNKNOWN And how often?  00:06:40UNKNOWN Not often. Two, four times a week, sometimes none. It’s expensive. So, you know, and then, you know, when you do get some, suddenly everybody is your best friend and you got to share, you know how it is.  00:07:00UNKNOWN Do you ever grow marijuana?  00:07:00UNKNOWN I used to. But then we moved and it’s not legal in this backward state. And where we live it’s pretty public, it’s not really private.  00:07:10UNKNOWN Do you ever have any side effects from using marijuana like memory problems?  00:07:15UNKNOWN I was born with memory problems, Doc, I don’t think it’s from the marijuana.  00:07:20UNKNOWN Any legal trouble with the marijuana?  00:07:25UNKNOWN Once. I mean, I’m super careful. But Zano, he went away for a year for selling like the tiniest little bit to an undercover cop, which is total entrapment, which is how I lost custody of Camper.  00:07:40UNKNOWN Camper?  00:07:45UNKNOWN My son.  00:07:45UNKNOWN Oh.  00:07:45UNKNOWN Yeah. He’s staying with my ex-husband’s parents right now. They take good care of him.  00:07:50UNKNOWN How long have you been divorced?  00:07:55UNKNOWN Oh, no, I never married that guy.  00:07:55UNKNOWN Oh.  00:07:55UNKNOWN No way I would marry that jerk. No, no, I don’t know. It’s been like four years since I’ve even seen him. Something like that, four years.  00:08:05UNKNOWN What happened?  00:08:10UNKNOWN Lucas, my ex, he freaked out because he caught me doing just a few lines of coke, but like everybody was doing it back then. So I… Anyway, his mom found the mirror, and the razors, and Lucas said I had to quit. But… For whatever I lied, and when he caught me, I know it was bad to lie about that, but I don’t know it’s in the past. You know, like, water under the bridge. You live, you learn, you move on.  00:08:50UNKNOWN Right. Do you use cocaine now?  00:08:50UNKNOWN No, hardly ever. I don’t know, it’s been like a month maybe, or two months or something since I have.  00:09:00UNKNOWN Any legal problems from using cocaine or…?  00:09:05UNKNOWN No. No, I mean, we hardly ever do it. So, yeah.  00:09:10UNKNOWN Have you thought about stopping altogether?  00:09:15UNKNOWN I mean, I hardly ever do it. Like, hardly even counts. I don’t know, when I do it, it’s just to relieve tension or, you know, it’s this thing Zano and I do to bring each other closer together, you know, but, like I could quit anytime I wanted, easy.  00:09:35UNKNOWN Does your boyfriend have children?  00:09:35UNKNOWN Yeah, yeah, he’s got two kids. Yeah. Yeah, but we don’t see them much. You know, his other with his ex.  00:09:45UNKNOWN Oh?  00:09:50UNKNOWN She’s like a real snobby type. You know the type? And it is a freaking tragedy because I see his two kids just going down that same path. You know, they’re just two little snobs. It’s a real shame. She… We’re not allowed to see them anymore though, so I guess, you know, like what’s the difference? She went to court and said we were unsuitable. Not suitable. You know, says it all real nice in court, and then not so nice over the phone, if you know what I mean? She’s a real bitch.  00:10:25UNKNOWN Any other drugs? Ecstasy? LSD?  00:10:30UNKNOWN All right. This is going to make me sound like I’m some 1970s hippy, druggo person. But I’ve tried ecstasy twice, just twice, and LSD once, last year. That was a bad trip. I am not doing that again.  00:10:55UNKNOWN Anything else?  00:10:55UNKNOWN Like what?  00:10:55UNKNOWN Stimulants?  00:11:00UNKNOWN Like power drinks if I need to stay up?  00:11:05UNKNOWN Sure.  00:11:05UNKNOWN Caffeine, I drink a lot of coffee. I don’t know if cigarettes, do they count as stimulants?  00:11:10UNKNOWN Yeah.  00:11:15UNKNOWN Yeah, I’m trying to cut back. Two packs a day.  00:11:15UNKNOWN Ritalin, Dexedrine?  00:11:20UNKNOWN Oh, like stimulants?  00:11:20UNKNOWN Right.  00:11:25UNKNOWN Oh, yeah. Not a lot. Like hardly ever. I mean, like if Zano and I are down for whatever reason, or sluggish like, from smoking pot, or just like if I need to get back up again. Yeah, like Adderall, just 20 helps.  00:11:40UNKNOWN Do you ever take prescription medications that are not prescribed for you?  00:11:45UNKNOWN Well, are you kidding me? Why would I do that? I told you I don’t like medications in the first place.  00:11:55UNKNOWN Klonopin, Ativan, Xanax?  00:11:55UNKNOWN Oh, those?  00:11:55UNKNOWN Yeah.  00:12:00UNKNOWN Yeah, I mean if, if my anxiety is acting up, if my meditation isn’t working? Yeah, a couple of Xana bars, you know, but not a lot.  00:12:15UNKNOWN How often would you estimate that is?  00:12:15UNKNOWN I don’t know. Two? I don’t know. I need like a freaking calendar to keep up with all your questions, Doc, God.  00:12:30UNKNOWN So in the past, who prescribed the oxycodone for you?  00:12:35UNKNOWN No one yet. Zano, he takes them because he’s got shoulder and back problems, and I tried one and, oh, man, it really works. To be honest it works fantastic.  00:12:50[sil.]  00:12:55END TRANSCRIPT