Comprehensive Case Study

Use the headings and subheadings below to develop the Comprehensive Case Study:

This is an academic paper – please start early to ensure you provide all the necessary information needed – your clinical instructor needs to “see” what you are seeing and thinking – please provide explanations and details.  Each subheading may require a paragraph or more describing your findings. There is a PART ONE and a PART TWO with this assignment, please review the rubric in the assignments.  The assessment findings should be relevant, thorough, and reflective of the standards associated with the professional psychiatric mental health nurse practitioner. Your plan should be individualized, based on sound evidence-based practice findings from the literature while incorporating all relevant findings from your assessment.

You should articulate this case study as if you were presenting it to a colleague for consultation or at a professional meeting. You may choose to develop this Comprehensive Case Study on a challenging or interesting patient encountered during your clinical experiences.

Please be organized and succinct when writing. Remember to proofread for logical flow, grammar, and typographical errors. Try to obtain all of the required information for your case study by reviewing the patient’s chart, talking with the patient and/or support person, and talking with the staff at your clinical site.

If some part of the required information is not available, you may state that there is no information available and what/how that component of the case study would normally be assessed to include expected normal findings. Include the information that you gathered in the appropriate section without repeating the same information multiple times. When you write any history of events, chronological order is required.

For guidance, review your readings and texts from the corresponding didactic course, other previous texts, and reference books. You must include references to support your assessment, differential diagnosis(es), primary diagnosis, and plan. There must be a minimum of 3 (three) references. At least 1 (one) of the references must be an evidence-based article that is no more than 5 years old used in the designated section of the rubric wherein you are also required to must rate and grade the evidence.

When you write your note, do not identify the person by name or initials. Use descriptions such as “the patient, the client, him, he, she, he, they, them, mother, father, husband, wife, first son, second daughter, youngest daughter, paternal grandmother, maternal grandfather, and so on. Do not state the name of the town and state. Use descriptions such as a rural town in a southwestern state, or a large city in a northeastern state, and so on.

Comprehensive Case Study Outline:

On the title page: include course number and section, student name, clinic setting, preceptor, faculty, referred by, informant/support person, and date. If completing a case study on a child (one is required for the program) use the Guidance for Child/Adolescent patient in Appendix D)

Demographics: (Age, marital status, sex, occupation, language, ethnic background, religion, geographical location, current living circumstances, whether referred or brought by someone) (Guidance for Child/Adolescent patient in Appendix D.)

Reason for Evaluation: The purpose of the evaluation influences the focus of the examination and the form of documentation.  The reason for evaluation should be elicited in sufficient detail, including the patient’s words, to permit an understanding of the duration of the complaint and the patient’s specific goals for the evaluation.

Chief Complaint: (Patient’s own words in quotes)  (Guidance for Child/Adolescent patient in Appendix D)

History of Present Illness: (Chronological picture of the events that brought the patient to treatment, onset of current episode, precipitating factors)

Past Psychiatric History: (First episode of illness, types of treatments, hospitalizations, suicidal attempts, assaultive behavior, psychiatric medications, previous therapy)

Medical History: (Allergies, review of symptoms, summary of neurological exam findings, any major medical illnesses, surgeries, head trauma, tumors, seizures, infectious diseases, sexually transmitted infections, autoimmune diseases, exposure to environmental hazards or toxins, hospitalizations, recent international travel; include current medications, appetite, sleep pattern, sexual behavior, immunization status, and recommended preventative care status)

Substance Use History: (Description of a pattern of alcohol and/or drug [illicit or prescribed] abuse. Include any history of substance-related blackouts or seizures or any intravenous drug use.) Use chart in Appendix A.

Developmental, psychosocial, and sociocultural history (Guidance for Child/Adolescent patient in Appendix D)

Family History: (Psychiatric illnesses, hospitalizations, and substance abuse back to maternal and paternal grandparents)

Developmental history to include: Perinatal: (Perinatal exposure to alcohol or drugs, full-term birth, vaginal or C- section, breast or bottle-fed)  Childhood: (Developmental milestones, history of head-banging, rocking, attachment history, separation anxiety, gender identity development, friendships, intellectual and motor skill, learning disabilities, nightmares, phobias, bedwetting, fire setting, cruelty to animals), Adolescence: (School groups, activities, sports, sexual activity, self-esteem, body image), Adulthood: (Employment, hobbies, relationships, legal, higher education, etc.)

Developmental Theory: Choose a different developmental theorist for each Case Study; study the theory and write no more than one page pertaining to this patient. Theorist options include Freud, Erikson, Piaget, Mahler, Kohlberg, Vygotsky, Bowlby, Bronfenbrenner.

Trauma/Abuse History: Describe characteristics of exposure to trauma, such as violence, sexual abuse, and/or medical trauma.

Social History:  Several paragraphs, as necessary, regarding friendships, vocational history/performance, available social support network, disruptions in the previous social support network, issues such as sociopathy or isolation, religious involvement, academic performance, socioeconomic status, etc.

Legal History:  Describe past or current involvement with the legal system. (see APA practice guideline)

Occupational and military history: What is the patient’s occupation, what jobs have they held. Are they able to work, what work skills and strengths do they have, and military service and combat (see APA practice guideline).

Cultural History: Write 1-2 paragraphs on (a) important aspects of this patient’s cultural background which informs their present way of living, (b) implications of the patient’s cultural background to their beliefs regarding medical practices, and (c) cultural accommodations for this patient in delivering care.  Include grandparent’s, parent’s, and patient’s country of origin.  Use a specific cultural textbook and/or journal article.

REVIEW OF SYSTEMS:

Include all relevant ROS, there should be no diagnosis in ROS. Students may use the ROS checklist or develop their own

Mental Status Examination:

Appearance and general behavior: In describing the patient’s appearance, factors such as approximate age, body habitus, dress, grooming, hygiene, and distinguishing features (e.g., scars, tattoos) may be noted. The patient’s general behavior, level of distress, degree of eye contact, and attitude toward the interviewer are also considered.  Remember to paint a clear picture so the reader can see and experience what you are.

Psychomotor Activity: The patient’s level of psychomotor activity is noted, as is the presence of any gait abnormalities or purposeless, repetitive, or unusual postures or movements (e.g., tremors, dyskinesias, akathisia, mannerisms, tics, stereotypies, catatonic posturing, echopraxia, apparent responses to hallucinations).

Speech: Characteristics of the patient’s speech are described and may include consideration of rate, rhythm, volume, amount, accent, inflection, fluency, and articulation.

Mood: (Depressed, irritable, anxious, angry, expansive, euphoric, empty, guilty, hopeless, self-contemptuous, frightened, perplexed, labile)

Affect: (Congruent with mood, normal range, constricted, blunted, flat) Affect is often described in terms of its range, intensity, stability, appropriateness, and congruence with the topic being discussed in the interview.

Thought processes: Features of the patient’s associations and flow of ideas are described, such as vagueness, incoherence, circumstantiality, tangentiality, neologisms, perseveration, flight of ideas, loose or idiosyncratic associations, and self-contradictory statements.

Thought content: The patient’s current thought content is assessed by noting the patient’s spontaneously expressed worries, concerns, thoughts, and impulses, as well as through specific questioning about commonly observed symptoms of specific mental disorders. These symptoms include delusions (e.g., erotomania or delusions of persecution, passivity, grandeur, infidelity, infestation, poverty, somatic illness, guilt, worthlessness, thought insertion, thought withdrawal or thought broadcasting), ideas of reference, overvalued ideas, ruminations, obsessions, compulsions, and phobias. Assessment of suicidal, homicidal, aggressive, or self-injurious thoughts, feelings, or impulses is essential for determining the patient’s level of risk to self or others as part of the clinical formulation. If such features are present, details are elicited regarding their intensity and specificity, when they occur, and what prevents the patient from acting on them

Perceptual disturbances: Hallucinations (i.e., a perception in the absence of a stimulus) and illusions (i.e., an erroneous perception in the presence of a stimulus) may occur in any sensory modality (e.g., auditory, visual, tactile, olfactory, gustatory). Other perceptual disturbances that patients may experience include depersonalization and derealization.

Sensorium and cognition: Systematic assessment of cognitive functions is an essential part of the general psychiatric evaluation, although the level of detail necessary and the appropriateness of particular formal tests will depend on the purpose of the evaluation and the psychiatrist’s clinical judgment. Evaluation of the patient’s sensorium includes a description of the level of consciousness and its stability. Elements of the patient’s cognitive status that may be assessed include orientation (e.g., person, place, time, situation), attention and concentration, and memory (e.g., registration, short-term, long-term). Arithmetic calculations may be used to assess concentration or knowledge; other aspects of the patient’s fund of knowledge may also be assessed as appropriate to sociocultural and educational background. Additional aspects of the cognitive examination may include assessment of level of intelligence, language functions (e.g., naming, comprehension, repetition, reading, writing), drawing (e.g., copying a figure or drawing a clock face), abstract reasoning (e.g., explaining similarities or interpreting proverbs), and executive functions (e.g., list-making, inhibiting impulsive answers, resisting distraction, recognizing contradictions).

Impulse Control: (Difficulty controlling immediate reaction, e.g., blurting out answers to questions or inappropriate comments. Among children and adolescents may be evidenced by touching or grabbing objects in the room during the evaluation.)

Insight: The patient’s insight into his or her current situation is typically assessed by inquiring about the patient’s awareness of any problems and their implications. Patients may or may not recognize that psychosis or other symptoms may reflect an underlying illness or that their behavior affects their relationships with other individuals. They also may or may not recognize the potential benefits of treatment. Another element of insight involves the patient’s motivation to change his or her health risk behaviors. Such motivation often fluctuates over time from denial and resistance to ambivalence to commitment, a sequence that has been referred to as “stages of change”. The stages, which are not necessarily discrete, have been labeled pre-contemplation (denial, minimization); contemplation (musing or thinking about doing something); preparation (actually getting ready to do something); action (implementing concrete actions to deal with the problem); and maintenance (acting to ensure that the changes are maintained). Patients who are not quite ready to change may vacillate about modifying their behaviors before actually committing to change and acting on it. Assessing stages of change as part of the evaluative process leads to stage-appropriate educational and therapeutic interventions that attempt to help patients move to more adaptive stages in a patient-centered manner.

Judgment: The quality of the patient’s judgment has sometimes been assessed by asking for the patient’s responses to hypothetical situations (e.g., smelling smoke in a theater). However, in assessing judgment, it is generally more helpful to learn about the patient’s responses and decision-making in terms of his or her own self-care, interactions, and other aspects of his or her recent or current situation and behavior. If poor judgment is present, a more detailed explication of the patient’s decision-making processes may help differentiate the potential causes of this impairment.

Cranial Nerves:

Cranial Nerves Assessment: Use the Cranial Nerves Documentation appendix.

PART TWO OF THE COMPREHENSIVE CASE STUDY Diagnoses

Differentials: Three differential diagnoses including pertinent patient presentation/symptoms that should be considered and must be plausible to match the patient presentation.  The student should write in detail WHY they thought the patient met this criterion using the previous information presented in part one and how the diagnosis was ruled out. The final diagnosis should NOT be included in the differential.

DSM-5 Final Diagnosis with ICD-10 Code: What is the rationale for the diagnosis? The student should write in detail the rationale that describes the specific symptomatology that qualifies the clinical presentation to be identified as the DSM-5 diagnosis, including diagnostic specifiers.

Formulating the Treatment Strategy

EBP:  Review an Evidence-Based Practice article referring to this patient with this particular diagnosis, treatment, or medication (summarize the study, include a rating of the article, (citation for the rating scale & put the article and rating scale in your references), instruments utilized, relevant findings.

Measurement of patient progress and Assessment Tools: List 2-3 measures that could be utilized for this patient in the future to measure their progress and provide an overall summary of these tools. Include the name of the test, information about reliability & validity, score ranges, the meaning of high vs low scores, how often the instrument should be administered, and the patient score is assessed during evaluation.  Mnemonic devices, such as “SIGECAPS” are not published/validated tests.

Psychopharmacology: Medication with dose-instructions listed, pharmacodynamics, and pharmacokinetics. A detailed explanation is provided for the choice of this medication over other medications in the same category.

Diagnostic tests: Diagnostic tests that are specific to the case are described with the rationale. Lab/Diagnostic template in Appendix A below. List each test separately and provide the rationale (CBC is separated by each test – hemoglobin, hematocrit, etc and what abnormals could mean and the possible connection to a psychiatric diagnosis if applicable.

Psychotherapy: List 2 or more theoretical orientations which could be used in the treatment of this patient and give 3-4 sentences describing each theoretical orientation and why the treatment could be beneficial. Such options could include Interpersonal, psychodynamic, EMDR, Rogerian, CBT, Jungian, etc. Use references other than Sadler or Wheeler.

Psychoeducation: Pertinent information regarding aftercare, legal issues, health promotion such as diet, medical, psychological testing, medications, diagnosis, black box warnings, and educational websites

Follow-up: Instructions to the patient for follow-up visits, emergency access, or diagnostics.  Include safety measures if indicated.

References:  APA format and writing