Case Study For A Patient With A History Of Medicine Inconsistency

Case Study For A Patient With A History Of Medicine Inconsistency

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Initials: P.P

CC (chief complaint): “I have a history of medicine inconsistency. I feel like I no longer want them.”

HPI: P.P., a 25-year-old female of Caucasian origin, has been referred to the clinic for a mental health checkup. P.P. reports depression, bipolar disorder, and anxiety history and is under no medications currently. P.P. reports using a particular drug but does not remember the name apart from the letter “L,” which, despite its help to her, ended up squashing her creativity. The client also reports previous hospitalizations that were four in number and which were due to mental health treatment. P.P. reports that the first hospitalization occurred during her teenage years after experiencing no sleep for approximately four or five days. She also reports that she would hear things that led to her mother admitting her to receive mental health treatment. P.P. also reports that in 2017, she had idealized suicide after a Benadryl overdose. However, P. P.’s recent hospitalization happened in 2020’s spring after police took her to the emergency department after finding her dancing and playing guitar in her nightgown (Walden University, 2021)Case Study For A Patient With A History Of Medicine Inconsistency.

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Other issues that P.P. reports include the four or five times every year when she loses interest in getting out of her bed, loses motivation, and loses affection for being creative. The patient also reports that during such a period, most people believe that she must be depressed, though she has never been sure of such a situation. However, when she feels motivated and energized during creativity periods, she fails to take her medications and can go to even five days without sleep. During that time, P. P.’s friend also perceives her as too talkative and appears scattered while she also reports on being pernicious, which may last for a week during the creative episodes.

Substance Current Use: P.P. reports that she smokes one packet of cigarettes daily. She denies cannabis, indicating that it makes her paranoid. She also denies alcohol use since she “Don’t do well” with alcohol. P.P. also reports that she last used alcohol at 19 years old. However, she denies ever indulging in inhalants, opioids, hallucinogens, benzodiazepines, and stimulants.

Medical History: P.P has a history of Polycystic ovarian syndrome and hypothyroidism.

• Current Medications: Hypothyroidism medication that the client cannot recall its name and oral contraceptives pills.
• Allergies: P has no known allergies.

• Reproductive Hx: P.P is sexually active and has multiple partners. Also, P.P’s last menses was last month. Case Study For A Patient With A History Of Medicine Inconsistency

ROS:

• GENERAL:P denies weight gain or loss. However, she reports excessive insomnia, high creatuivity and energy periods which then follows hypersomnia, low motivation and low energy periods.
• HEENT: The patient denies dizziness, headaches, ear pain, epistaxis, or eye pain. Also, the client denies blurry vision, vision changes and nasal discharge. The patient also denies swallowing difficulties.
• SKIN: The patient denies of a possible skin rashes or abnormal brusing.
• CARDIOVASCULAR: The patient denies of shortness of breath or chest tightness or pain.
• RESPIRATORY: The patient denies coughing, breath shortness or nocturnal dyspenea.
• GASTROINTESTINAL:P denies constipation, diarrhear or gastrointestinal upset.
• GENITOURINARY: The patient denies painful urination, urinary urgency or frequency.
• NEUROLOGICAL: The patient denies ataxia, numbness or headaches.
• MUSCULOSKELETAL: Denies joint or muscle pain.
• HEMATOLOGIC: Denies abnormal bruising or bleeding.
• LYMPHATICS: Denies painful or swollen lymph nodes.
• ENDOCRINOLOGIC: The patient reports hypothyroidism Case Study For A Patient With A History Of Medicine Inconsistency.

Objective:

Diagnostic results: There are no diagnostics for P.P. completed currently. However, the labs must be completed before starting medication. These labs include a comprehensive metabiotic panel, thyroid stimulating hormone, complete blood count (CBC), fasting lipids, free t3 and t4, urine toxicology, pregnancy testing, and electrocardiogram (EKG).

Assessment

Mental Status Examination: 

P.P., a 25-year-old female of Caucasian origin, resembles the stated age, including her well-grooming and dressing that resonate with the weather. The patient is alert and oriented to place, time, and self. The patient’s affect is bright but with a pressured speech. Her mood is euthymic and elevated, with her eye contact being good. Other factors, like her thought process, are presented as goal-directed and relevant. The patient’s remote and recent memory is intact. The patient has no psychomotor retardation or agitation while her fund of knowledge resonates with her age. However, the patient expresses delusional thoughts concerning her makeup artist, making her more obsessed with Picasso’s artwork. The patient reports suicidal ideations but denies homicidal ideations. She denies visual and auditory hallucinations. Also, she fails to fathom her bipolar disorder since she believes in her creativity despite its mania symptoms. The patient’s judgment is poor since she does not acknowledge the impact of stopping her medications. Case Study For A Patient With A History Of Medicine Inconsistency

Diagnostic Impression

Bipolar 1 Disorder (F31.2), Moderate.

Bipolar 1 Disorder is classified as a mood disorder that involves labile moods that revolve around depression to mania. According to Kowalewski et al. (2021), the DSM-5 criteria characterizes the condition symptom to include mania episodes alternating with depression bouts. These symptoms may prevail with the presence or absence of psychosis. Other symptoms include inflated self-esteem, hyperverbal speech, impulse behaviors, and racing thoughts (Kowalewski et al., 2021). The case study patient presents insomnia, depressed moods, low motivation and energy, racing thoughts, and elevated moods, making Bipolar 1 Disorder the primary diagnosis. That is because some of these symptoms may last even for a week.

Attention-Deficit Hyperactivity Disorder (ADHD, F90.1)

ADHD is defined as a neurodevelopmental disorder that incorporates inattentiveness or hyperactivity symptoms or, in some cases, both disorders. According to Jennum et al. (2020), the patient has to be diagnosed with ADHD symptoms like impulsivity and hyperactivity within less than six months, impaired social and academic functioning, hyperverbal speech, issues with completing tasks, and intrusive behaviors like interrupting conversations and activities (Jennum et al., 2020)Case Study For A Patient With A History Of Medicine Inconsistency. For the patient under study, she is hyperverbal, impulsive, and hyperactive but it is ruled out since the symptoms lasts for long.

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Generalized Anxiety Disorder (GAD, F41.1)

GAD is one of the anxiety disorders where individuals worry excessively and experience restlessness periods, sleep disturbance, and irritability for six or more months (Thibaut, 2022). The impact of these symptoms includes occupation and social functioning. The case study patient reports instances of hypersomnia and insomnia but it is ruled out since the symptoms occurs over six months.

Unspecified Depressive Disorder that involves mixed features (F32.9)

The condition is a mood disorder that incorporates expansive and elevated mood symptoms with a sense of hyperverbal speech, high self-esteem, grandiosity sense, racing thoughts, and pressured speech (Stahl, 2017). Other symptoms may include sexual, occupational, and social activities, increased energy levels, and a decreased sleep need. The patient reports risky and impulsive behaviors, poor sleep, and pressured speech in the case study but it is ruled out since the symptoms can be specified to make informed decision on the patient condition.

Reflections

From the case study, the issue noted first is confidentiality. That is because healthcare providers need to protect the patient’s names and other details that may affect their personal lives (Stahl, 2017). For instance, Dr. Moore fails to adhere to that rule and discloses the patient’s name. That is in consideration that some confidential information, like the patient’s sexual activeness with multiple partners, may impact her future relationship with a spouse or her family members. Patient education is another important factor to consider when evaluating the patient’s condition (Stahl, 2017). P.P. reports that she has been engaging in inconsistent medication intake. Hence, the attending physician should ensure that P.P. is enlightened on alternatives like involving her most trusted family member in her treatment plan to ensure that she takes her medicines during that period (Kowalewski et al., 2021)Case Study For A Patient With A History Of Medicine Inconsistency. The patient must also be enlightened on the need to engage in safe sex to avoid sexually transmitted infections like HIV/AIDS. In such a case, the healthcare provider will have adhered to the autonomy, beneficence, and nonmaleficence bioethics principles that increase the chance for positive patient health outcomes.

Case Formulation and Treatment Plan:

P.P.’s primary diagnosis is Bipolar 1 disorder, evidenced by the patient’s moods, which involve depressive episodes and periods that alternate with mania periods. However, before treating the patient, there will be a need to seek her consent to access her medical history to ascertain the medication “L,” which seems complicated to remember. That will prevent contraindications since patients may be easily affected by different medicine interactions (Stahl, 2017). Another important lab necessary before any treatment is complete blood work to evaluate renal function, pregnancy, and liver function.

In that case, the patient must be administered with Depakote 250mg twice daily and olanzapine 2.5mg daily by mouth. However, it will be necessary to assess the patient’s valproate or valproic acid since it helps in treating manic, mixed, and acute episodes and in managing bipolar patients (Kowalewski et al., 2021)Case Study For A Patient With A History Of Medicine Inconsistency. However, if blood tests show that the patient is pregnant, there will be a need to withdraw Depakote since it may cause congenital malformations. Apart from such pharmacological interventions, the main non-pharmacological that the patients may be introduced to include psychotherapy, which may promote remission and prevent relapse of bipolar episodes (Stahl, 2017). From a clinical point of view, managing bipolar 1 disorder is more effective and successful through combining non-pharmacological and pharmacological interventions.

References

Jennum, P., Hastrup, L. H., Ibsen, R., Kjellberg, J., & Simonsen, E. (2020). Welfare consequences for people diagnosed with attention deficit hyperactivity disorder (ADHD): A matched nationwide study in Denmark. European Neuropsychopharmacology, 37, 29–38. https://doi.org/10.1016/j.euroneuro.2020.04.010

Kowalewski, W., Walczak-Kozłowska, T., Walczak, E., & Bikun, D. (2021). Nursing care in bipolar disorder – case study. Pomeranian Journal of Life Sciences, 67(1). https://doi.org/10.21164/pomjlifesci.772

Stahl, S. M. (2017). Stahl’s essential psychopharmacology: Neuroscientific basis and practical

               applications (6th ed.). Cambridge University Press

Thibaut, F. (2022). Anxiety disorders: a review of current literature. Generalized Anxiety Disorders, 19(2), 87–88. https://doi.org/10.31887/dcns.2017.19.2/fthibaut

Walden University. (2021). Case study: Petunia Park. Walden University Blackboard https://class.waldenu.edu Case Study For A Patient With A History Of Medicine Inconsistency

INSTRUCTIONS ON HOW TO USE EXEMPLAR AND TEMPLATE—READ CAREFULLY

If you are struggling with the format or remembering what to include, follow the Focused SOAP Note Evaluation Template AND the Rubric as your guide.  It is also helpful to review the rubric in detail in order not to lose points unnecessarily because you missed something required.  After reviewing full details of the rubric, you can use it as a guide.

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

Read rating descriptions to see the grading standards! 

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.

Read rating descriptions to see the grading standards!

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.
• Read rating descriptions to see the grading standards!

Reflect on this case. Include: 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.)Case Study For A Patient With A History Of Medicine Inconsistency.

(The FOCUSED SOAP psychiatric evaluation is typically the follow-up visit patient note. You will practice writing this type of note in this course. You will be focusing more on the symptoms from your differential diagnosis from the comprehensive psychiatric evaluation narrowing to your diagnostic impression. You will write up what symptoms are present and what symptoms are not present from illnesses to demonstrate you have indeed assessed for illnesses which could be impacting your patient. For example, anxiety symptoms, depressive symptoms, bipolar symptoms, psychosis symptoms, substance use, etc.)

EXEMPLAR BEGINS HERE

Subjective:

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 medication management follow up for anxiety. He was initiated sertraline last appt which he finds was effective for two weeks then symptoms began to return.

Or

P.H., a 16-year-old Hispanic female, presents for follow up to discuss previous psychiatric evaluation for concentration difficulty. She is not currently prescribed psychotropic medications as we deferred until further testing and screening was conducted.

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. First what is bringing the patient to your follow up evaluation? Document symptom onset, duration, frequency, severity, and impact. What has worsened or improved since last appointment? What stressors are they facing? Your description here will guide your differential diagnoses into your diagnostic impression. 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.

Substance Use History: This section contains any history or current use of caffeine, nicotine, illicit substance (including marijuana)Case Study For A Patient With A History Of Medicine Inconsistency, 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.

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.

Objective: Case Study For A Patient With A History Of Medicine Inconsistency

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.

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.

Diagnostic Impression: You must begin to narrow your differential diagnosis to your diagnostic impression.  You must explain how and why (your rationale) you ruled out any of your differential diagnoses. You must explain how and why (your rationale) you concluded to your diagnostic impression.  You will use supporting evidence from the literature to support your rationale. 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!), 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.)Case Study For A Patient With A History Of Medicine Inconsistency.

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Case Formulation and Treatment Plan

Includes documentation of diagnostic studies that will be obtained, referrals to other health care providers, therapeutic interventions including psychotherapy and/or psychopharmacology, education, disposition of the patient, and any planned follow-up visits. Each diagnosis or condition documented in the assessment should be addressed in the plan. The details of the plan should follow an orderly manner.  *See an example below. You will modify to your practice so there may be information excluded/included. If you are completing this for a practicum, what does your preceptor document?

Risks and benefits of medications are discussed including non- treatment. Potential side effects of medications discussed (be detailed in what side effects discussed). Informed client not to stop medication abruptly without discussing with providers. Instructed to call and report any adverse reactions. Discussed risk of medication with pregnancy/fetus, encouraged birth control, discussed if does become pregnant to inform provider as soon as possible. Discussed how some medications might decreased birth control pill, would need back up method (exclude for males).

Discussed risks of mixing medications with OTC drugs, herbal, alcohol/illegal drugs. Instructed to avoid this practice. Encouraged abstinence. Discussed how drugs/alcohol affect mental health, physical health, sleep architecture.

Initiation of (list out any medication and why prescribed, any therapy services or referrals to specialist): Case Study For A Patient With A History Of Medicine Inconsistency

Client was encouraged to continue with case management and/or therapy services (if not provided by you)

Client has emergency numbers:  Emergency Services 911, the  Client’s Crisis Line 1-800-_______. Client instructed to go to nearest ER or call 911 if they become actively suicidal and/or homicidal. (only if you or preceptor provided them)

Reviewed hospital records/therapist records for collaborative information; Reviewed PMP report (only if actually completed)

Time allowed for questions and answers provided. Provided supportive listening. Client appeared to understand discussion. Client is amenable with this plan and agrees to follow treatment regimen as discussed. (this relates to informed consent; you will need to assess their understanding and agreement) Case Study For A Patient With A History Of Medicine Inconsistency

Follow up with PCP as needed and/or for:

Labs ordered and/or reviewed (write out what diagnostic test ordered, rationale for ordering, and if discussed fasting/non fasting or other patient education)

Return to clinic:

Continued treatment is medically necessary to address chronic symptoms, improve functioning, and prevent the need for a higher level of care.

 References (move to begin on next page)

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 Case Study For A Patient With A History Of Medicine Inconsistency