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Week 7: Complex Case Study Presentation

Elizabeth Jallah

College of Nursing-PMHNP, Walden University

PRAC 6675: PMHNP Care Across the Lifespan II Practicum

Instructor: Dr. Mihaela Fletcher

July 11,2023

Objectives 1) Adhere to DsM-v manuar criteria for primaryand secondary differentiars

diagnosis.

2) Recognize the actual presenting signs and symptoms of adjustment disorder. 3) Assess and plan for the appropriate intervention for adjustment disorder. 4) lmplement the approved psychotherapy intervention for adjustment disorder!

D+.flrntO*,t PhD(c), DNP, MSN-Ed,

APRN.BC, MAC tu q/o+/a4

@ 2021 Walden University Page 2 of 9

Subjective:

CC: "I can't stop the tears; I have nothing to live for now."

HPI: N. P. is a 39-years- old African American female referred to the clinic by her

PCP for psychiatric evaluation. N. P. is escorted by her husband, Dave, of 11

years. Dave reported that he is worried about her. He noticed since the death of their ten-years-old-son two months ago from Leukemia, and she does look the

same. She had lost weight, been withdrawn, keeping to herself. Every time he sees

her, she cries and has not been eating much. He told Nancy she did not look well and encouraged her to see the doctor. He stated that he and N. P. went to Jamaica

for a four days vacation to break from the grieving. While in Jamaica,he noticed

that N. P. didn't leave the hotel room. She spent all her time in the hotel. N. P.

reported that the memories of her son are heavy on her heart and mind. She tried thinking about other things, but her thoughts were fixed onhim. N. P. added

feeling tired and not in the mood to do anything. Her appetite is poor; she sleeps 14

to 16 hours daily and is slow on her feet. She stopped working six months ago to

care for their son, who needed chemotherapy and has been isolated from everyone

since.

Psychiatric History: No record of previous and present.

Caregivers: The Patient lives with her husband.

Substance Current Use and History: She denied substance use.

Medical History: Current Medications: She admitted taking Tylenol 650mg po PRN for headaches. Allergies: No known drug, seasonal, food, or environmental allergies

Reproductive Hx: The Patient is heterosexual. She is married and has one son.

ROS: GENERAL: Recent weight loss. She admitted to tiredness and fatigue but denied

fever and chills. O,v.foulaorrto nrro(g).bNp, MSN-Ed, fr*A,

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HEENT: No visual loss, blurred vision, or double vision. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.

SKIN: No rash, itching, or bruising.

CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.

RESPIRATORY: No wheezes, shortness of breath, or cough GASTROINTESTINAL: Poor appetite, no nausea, vomiting, or diarrhea. No abdominal pain GENITOURINARY: No burning on urination, urgency, hesitancy, or odor NEUROLOGICAL: occasional headache. No dizziness, syncope, paralysis, or ataxia. No change in bowel or bladder control. MUSCULOSKELETAL: No muscle issues, stiffness, or back pain.

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:

Diagnostic results: The SCID-I is a clinician-administered, semi-structured interview for use with psychiatric patients undergoing evaluation for psychopathology. The SCID-I is the most user-friendly of the clinician- administered interviews used to assess depression status and makes diagnoses

according to the current DSM (Sanchez-Villegas et a1.,2008).

TSH, CBC, and CMP test was completed to rule out any medical relationships,

and their levels are normal.

Thyroid panel: Thyroid abnormalities can induce mood, Anxiety, psychotic, and cognitive disorders. Thyroid function tests are routinely checked in psychiatric patients. In psychiatric patients with non-thyroidal illness, thyroid function test abnormalities may vary considerably based on factors such as the

underlying psychiatric Disorder (Dickernan & Bamhill, 2012).

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Assessment:

Mental status Examination: The Patient is a 39-year-old African Americanfemale who appeared her r ro r'rv r .tr.,,L

med and dressed e thought process is Iusions. N. p. short-term ment, and concentration.

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difficurt to tark to. iire patienil,u, ,o i.gar history and has never been

Differential Diagnoses: Adjustment diso.rder with depressed mood DSM-5 43.21: is a commonpsychiatric disorder. It is rno.. lik"^ly t9 a-.-*r;i;a a major depressivedisorder when stress is persistent ifpatie"t, d;;; deverop .rruJrjrl copingstrategies' Stress has been persistently present.J ro, over one year among overone-third of patients with AD. Psycnltir..upy ir r.guro.d as the most effective

depressive symptoms of AD (Hsiao et a1.,2014). Thisprimary differential diagnosis fcr Nun.y. iiecause these

keeping to herserr,u ,talll'il:i*l3lf,:lt ff:eating much, *i*,a,u*i,,g, und

Major Depressive Disorder DSM-5 F32.0: is considered a chronic, disabling, and recurring psychiatric condition which is charact erizedby depressed mood, reduced interest and pleasure in daily activities, weight fluctuation, sleep and psychomotor.distress, fatigue, feelings of worthlesrrr".i, trouble concentrating, and suicidal ideation (Mokhtari et at., zo-z). Although Nancy has been unhappy, feeling worthless, lack of energy, sreeping iong horr.r, and having a poor appetite, she didn't qualify for this diagnosis.

Posttraumatic stress disorder (prsD) DSM-5 F43.10: is a severe traumatic experience characterizedby flashbacks; nightmares; avoidan ce; asense of "numbness" and emotional blunting; anhedoni a, inda bursi of fear or panic. PTSD is associated with poor.i physical health, health-related quality of life, and lower life expectancy (Roer

"i u[.,2023).Even though the memories of

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APRN.BC. MAC-, @2021Walden University d/O{ru

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her son are heavy on her mind, this diagnosis does not fully represent Nancy's

symptoms.

Reflections: It wasn't easy formulating a treatment plan for N. P. If I had to do this assessment

over, I would have established a coping strategy to calm N. P. Because one minute, she would be involved in her care, excited about starting treatment, andthe next,

she would withdraw, stating, "I can get well on my own without treatment." I couldn't figure out her actual state of mind. However, I decided to start N. P. on psychotherapy intervention and monitor her progress since N. P. had no previous mood issues. Her depression was related to her son's death. I also educated Nancy that psychopharmacologic medication would be included in her treatment plan if no mood improvement occurred after a month of sessions. I was hopeful the

therapy would work because N. P. told me that although she loved and missed her

son deeply, it was time to return to work and reconnect with friends, especially her walking buddy, Pam. According to Hsiao et al. (2014), N. P. will benefit from psychosocial resilience factors that reduce stress-induced depression, including helping her maintain positive emotions, cognitive flexibility, spirituality, social

support, and active coping behaviors such as physical exercise.

After three weeks of receiving treatment twice a week, I ran into N. P. at the clinic. She appears upbeat. She stated that the therapy seemed to be working. She thanked

the counselor. She returned to attending church, working, and walking with Pam

five times a week in the park. As for her appetite, it has improved. She is back to eating three small meals per day. She is getting more comfortable in social gatherings, like going grocery shopping. She refused medication try at this time.

Case Formulation and Treatment Plan: 1. Based on this Patient's history, behaviors , at\d symptoms, the best treatment plan for her is psychotherapy (Individual and couple counseling). Psychotherapy is regarded as the most effective treatment for decreasing depressive symptoms of AD. Supportive group therapy helps enhance coping skills in patients with AD, which might improve their psychobiological stress responses (Hsiao et a1.,2014).

2. Monitor weight, labs, diagnostic, and reviewed tests results 3. Encourage her to eat a balanced diet and exercise four to five days a week.

4. Encourage Nancy to go to the nearest ER or call 911 if she becomes suicidal or homicidal.

PhD(c), DNP, MSN-Ed, APRN.BC, MAC q/ryu'ry

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Questions:

1' Do you agree the Patient's primary diagnosis is adjustment disorder, or couldit be Major Depressive Disorder? at a wnyZ

2' Do you think this Patient can get well independently without psychoth erapy intervention?

3' Do you think this Patient will experience the same depressed mood When another family member dies?

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APRN.BC, MAC aV,fr/^g q

@ 2021 Walden University Page 7 of 9

References

ction tests in iatry, l69e), 127_

Mokhtari, s., Mokhtari, A., Bakizadeh, F., Moradi, A., &shalbafan ,M. (2023). cognitive rehabilitation for improving cognitive functions and reducing the severity of depressive symptoms in adult patients with Major Depressive Disorder: a systematic review and meta-analysis of randomized controlled clinical trials. BMC Psychiatry, 23(t),77 . https:lldoi.org/l0.1 I g6ls12ggg -023-04554-w

Roer, G. E., Lien, L., Bolstad, I., Aaseth, J. o., &Abebe, D. s. (2023).The impact of PTSD on risk of cardiometabolic diseases: a national patient cohort study in Norway. BMC Psychiatry, 23(l),349. https:l/doi.orgll0.1186/s12888 -023-04866-x

Sanchez-villegas, A., Schlatter, J., ortuno, F., Lahortiga, F., pla, J., Benito, s., & Martinez-Gonzalez, M.A. (2008). Validity of a self-reported diagnosis of depression among participants in a cohort study using the Structured Clinical Interview for DSM-IV (SCID-I). BMC Psychiatry , 8, 43. https ://doi. org/ I 0. L I 86 I I 47 l -244X-8 - 43

Yang, Z.-Y., Wang, Y.-T., Xia,L'Zheng, Y.-C., & Feng, Z.-2. (2022).The Relationships between Prospection, Self-Effi c acy, and Depression in College Students with Cross-Lagged Analysis. International Journal of Environmental Research and Public Heqlth, 19(22). https://doi.orgll0.3390lijerphl922l4685

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APRN.BC, MAC

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@ 2021 Walden University Page 9 of 9