NRNP 6635 Case History Reports

ByLeon Kiprotich Leon Updated on

NRNP 6635 Case History Reports

Week 3: Mood Disorders

Training Title 2

Name: Ms. Julie Houston Gender: female
Age:19 years old
T 98.1 P-78 R-18 119/74 Ht 5’2” Wt 184lbs

Background: Recently started a business undergraduate program in Boston, MA after growing up and living in South Carolina her whole life. Grew up with both parents, two brothers, and one sister. Currently lives in off-campus housing with two other female roommates. Currently a full-time student, not employed. Not married, currently single. She has no previous psychiatric history; takes no medications. There is no psychiatric or substance use history for her or family. No legal hx NKDA

Symptom Media. (Producer). (2016). Training title 2 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-2

Training Title 8

Name: Mrs. Leslie Tilman Gender: female

Age: 32 years old

T- 97.6 P- 97 R 22 149/98 Ht 5’3 Wt 245lbs

Background: Recently had her first child two months ago. Currently married; stay at home mother after working in retail for 5 years. Grew up with both parents, one sister in Omaha, NE. Completed education through bachelor’s level, studying physics. Previous employment included research science as well as high school substitute teaching for 5 years prior to birth. No previous suicidal gestures; has uncle who committed suicide via GSW. She denied drugs/alcohol; uncle was opioid abuser. Hx of HTN-prescribed labetalol 100mg twice daily, admits to missing doses due to forgetting. No legal hx. Allergies: codeine

Symptom Media. (Producer). (2016). Training title 8 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-8

Training Title 18

Name: Ms. Ashley Domingo Gender: female

Age:20 years old

T-97.9 P-68 R-18 118/82 Ht 5’1 Wt 120lbs

Background: Currently living off-base in California, active duty in the Army, MOS 92M Mortuary Affairs Specialist. Grew up in Houston, TX with both parents and one brother. Completed education through high school. Currently partnered. No children. Mother history of depression; brother hx of cannabis use. No medical history. No legal hx; NKDA

Symptom Media. (Producer). (2017). Training title 18 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-18

Training Title 28

Name: Mrs. Louise Carson Gender: female

Age: 49 years old

T- 98.8 P- 99 R 20 150/88 Ht 5’5 Wt 135lbs

Background: Currently living in Indianapolis, IN, working full-time as a logistics buyer in a medical facility. Has an MBA. Lives with her husband and three children, three boys who are all teenagers. Born and raised in Indianapolis, IN with her mother and two sisters. Father deceased in MVA when she was 2 years old. Sister has depression; mother has history of being a “functioning alcoholic”. Recently informed by her PCP she has a “fatty liver.” Allergies: latex

Symptom Media. (Producer). (2016). Training title 28 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-28

Training Title 38

(same patient in video 43 but presentation of his illness pre-hospitalization) Name: Mr. Will Loman

Gender: male Age:19 years old

T- 98.6 P- 94 R 24 128/78 Ht 5’7 Wt 152lbs

Background: Currently lives with his sister and two parents in Jacksonville, FL. Not currently employed. Completed high school, not currently in school. Hx of treatment for mood disorder began age 15, previous trials of Depakote, Olanzapine off and on, side effects of wt. gain. Has hx of a three-day hospitalization one year ago after found wandering on the side of the freeway, but he signed himself out ‘against medical advice.’ He refused medication due to previous experiences. Not currently partnered. He has been sexually inappropriate with comments to female neighbors; pulled his pants down in the mall. Denies any recent alcohol or substance use. Father has history of bipolar disorder. No history of self-harm behaviors, no

family suicides. Mother reports he has slept 2–3 hours in past week, up spending money buying and playing new video games and says he is writing a book on how others can be a video game master. Appetite is decreased. No medical hx; Hx of trespassing as a juvenile. Has pending court date for indecent exposure. Allergies: PCN

Symptom Media. (Producer). (2016). Training title 38 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-38

Training Title 43 – NRNP 6635 Case History Reports

(same patient in video 38 but presentation of his illness with hospital treatment)

Name: Mr. Will Loman Gender: male

Age:19 years old

T- 98.2 P- 74 R 18 120/70 Ht 5’7 Wt 156lbs

Background: Currently lives with his sister and two parents in Jacksonville, FL. Not currently employed. Completed high school, not currently in school. Hx of treatment for mood disorder began age 15, previous trials of Depakote, Olanzapine off and on, side effects of wt. gain. Has hx of a three-day hospitalization one year ago after found wandering on the side of the freeway, but he signed himself out ‘against medical advice.’ He refused medication due to previous experiences. Not currently partnered. He has been sexually inappropriate with comments to female neighbors; pulled his pants down in the mall. He is currently in hospital admitted one week ago, was initiated on lithium 300mg po three times daily and risperidone 1mg at bedtime. Denies any recent alcohol or substance use. Father has history of bipolar disorder. No history of self-harm behaviors, no family suicides. Mother reports he has slept 2–3 hours in past week, up spending money buying and playing new video games and says he is writing a book on how others can be a video game master. Appetite is decreased. No medical hx; hospital admission labs within normal ranges, UDS negative; Hx of trespassing as a juvenile. Has pending court date for indecent exposure. Allergies PCN

Symptom Media. (Producer). (2016). Training title 43 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-43

Training Title 150 Name: Ms. Liliana Ball Gender: female Age:16 years old

T- 97.4 P- 84 R 18 134/88 Ht 5’3 Wt 118lbs

Background: Currently living with her parents in Tacoma, WA along with two young siblings. She is a sophomore in high school, not currently partnered, reports she is bisexual, lately having lot of unprotected sex that her parents don’t know about. She has been stealing money out of her mom’s purse to buy clothes, makeup, “and just other things.” She has history of treatment since age 7 for conduct disorder, depression, history of taking sertraline which worsened her irritability, aggression, impulsivity.

She has been in a 3-month teen residential mental health facility discharged one month ago with lithium 300mg in am and 600mg at bedtime, aripiprazole 10mg in the morning. When discharged, her labs were within normal ranges and urine toxicology negative. She was positive for cannabis upon admission. Her parents believe she is hiding her medication as she has made comments “they slow me down; they crush my creative art.”

She has hx of domestic violence toward her mother and 2 younger sisters as juvenile. No current legal issues. Her grandmother has hx of bipolar disorder; her mother and her maternal aunt have anxiety. She is sleeping 3–4hrs/24 hrs. Reports her appetite “is great.” She has no medical issues; has Nexplanon implant; hx of self-harm with cutting.

Symptom Media. (Producer). (2018). Training title 150 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-150

Training Title 118 Name: Mr. Oscar Luna Gender: male

Age: 52 years old

T- 98.6 P- 90 R 24 140/84 Ht 5’8 Wt 170lbs

Background: Born and raised in Leopold, IN. Is staying at a shelter after being homeless in MacArthur Park for 1 year in Los Angeles. He lost his apartment and his job working part-time as a dishwasher. Enjoys playing music. He has long hx of mental health treatment since age 14. Previous medication trials include lithium (toxicity), Depakote (wt gain), aripiprazole (akathisia), risperidone (dystonia), haloperidol (didn’t give a fair trial), quetiapine (wt gain), reports in past helpful medication was lurasidone, lamotrigine, olanzapine but states “they really squash my creative song writing though.”

Poor historian. Never married, reports he is gay, no children; estranged from only living sister, parents deceased. He is not sure of his family mental health or substance use history but feels like he is most like his aunt, she has history of mental health treatment “but I’m not sure for what.” States that he got a master’s degree in music theory at Stanford. Admits to 1–3 drinks of alcohol when “playing music in the clubs”, denied illicit drugs, has history of overdose at age 28, history of 3 inpatient psychiatric hospitalization, most recent was 1 year ago. Allergies: doxycycline; hx of rosacea.

Symptom Media. (Producer). (2018). Training title 118 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-118

Training Title 144 Name: Ms. Amy Hartford Gender: female

Age: 32 years old

T- 98.2 P- 74 R 18 120/70 Ht 5’1 Wt 150lbs

Background: Currently lives in Phoenix, AZ, divorced with two children ages 10 and 8. Born and raised in Tucson, AZ with her mother and four sisters NKDA; no legal hx

Symptom Media. (Producer). (2018). Training title 144 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-144

NRNP 6635 Week 3: Assignment

ASSESSING AND DIAGNOSING PATIENTS WITH MOOD DISORDERS

Accurately diagnosing depressive disorders can be challenging given their periodic and, at times, cyclic nature. Some of these disorders occur in response to stressors and, depending on the cultural history of the client, may affect their decision to seek treatment. Bipolar disorders can also be difficult to properly diagnose. While clients with a bipolar or related disorder will likely have to contend with the disorder indefinitely, many find that the use of medication and evidence-based treatments have favorable outcomes.

TO PREPARE:

  • Review this week’s Learning Resources. Consider the insights they provide about assessing and diagnosing mood disorders.
  • Download the Comprehensive Psychiatric Evaluation Template, which you will use to complete this Assignment. Also review the Comprehensive Psychiatric Evaluation Exemplar to see an example of a completed evaluation document. 
  • By Day 1 of this week, select a specific video case study to use for this Assignment from the Video Case Selections choices in the Learning Resources. View your assigned video case and review the additional data for the case in the “Case History Reports” document, keeping the requirements of the evaluation template in mind.
  • 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. 

BY DAY 7 OF WEEK 3

Complete and submit your Comprehensive Psychiatric Evaluation, including your differential diagnosis and critical-thinking process to formulate a primary diagnosis. Incorporate the following into your responses in the template:

  • Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life? 
  • Objective: What observations did you make during the psychiatric assessment?  
  • Assessment: Discuss the patient’s mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses with supporting evidence, listed in order from highest priority to lowest priority. Compare the DSM-5-TR diagnostic criteria for each differential diagnosis and explain what DSM-5 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.
  • Reflection notes: What would you do differently with this client if you could conduct the session over? Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), 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.).

Video Case Selections for this Assignment

Select one of the following videos to use for your Assignment this week. Then, access the document “Case History Reports” and review the additional data about the patient in the specific video number you selected. 

NRNP 6635 Case History Reports Week 3: Assessing and Diagnosing Patients with Mood Disorders Example

Subjective:

CC (chief complaint): “Yeah, yesterday I was a little bit depressed, but it was just because I was in a bad mood.”

HPI: Ms. C.L. is an 18-year-old female who presents to the psychiatric clinic for a psychiatric evaluation for depression. She had been admitted to a mental health facility and discharged on lithium 300 mg in the morning and 600 mg during bedtime, and aripiprazole 2.5 mg in the morning. She has a history of taking citaprolam, which worsened her impulsivity, aggression, and irritability symptoms.

The patient agrees that the previous day she left a little depressed, as it is human nature to change moods. The parents reported that she had started crying and said she did not want to participate in more school plays. Additionally, they reported that she had lost her energy and had said she was worthless, thought she was destroying everyone’s life, and wanted to die. She refers to these reports as ancient history. These symptoms had only lasted for almost a week.

Past Psychiatric History:

  •       General Statement: She entered treatment for depression and conduct disorder at 9 years. She was also admitted to a residential mental health facility and discharged three months ago.
  •       Caregivers (if applicable): N/A
  •       Hospitalizations: Residential Mental Health Facility
  •       Medication trials: N/A
  •       Psychotherapy or Previous Psychiatric Diagnosis: Conduct disorder, depression

Substance Current Use and History: She tested positive for cannabis on admission.

Family Psychiatric/Substance Use History: The grandmother has a history of bipolar disorder. Her mother and aunt have a history of anxiety.

Psychosocial History: The client lives in Locust Grove, Oklahoma, with her parents, two younger sisters, and an older brother.

Medical History:

  •       Current Medications: She is on lithium 300 mg in the morning and 600 mg during bedtime, and aripiprazole 2.5 mg in the morning.
  •       Allergies: N/A
  • Reproductive Hx: She is not partnered and has no children. She is bisexual, and lately, she has been hyper-sexual with increased incidents of unprotected sex.

ROS:

  •       GENERAL: No apparent signs of loss of weight, fatigue, chills, or weakness.
  •       HEENT: Eyes: No loss of vision, diplopia, or yellowing of the sclera. Ears: No loss of hearing or discharge from ears. Nose & Throat: No sore throat, runny nose, congestion, or sneezing.
  •       SKIN: No itching or rash.
  •       CARDIOVASCULAR: No reports of chest pressure, chest pain, or chest discomfort. No edema or palpitations.
  •       RESPIRATORY: No cough, shortness of breath, or sputum.
  •       GASTROINTESTINAL: No reports of nausea, vomiting, diarrhea, abdominal pains, or blood in the stool.
  •       GENITOURINARY: No odd urine color, odor, or burning sensation on urination.
  •       NEUROLOGICAL: No reports of dizziness, paralysis, ataxia, headache, or tingling sensation of the extremities. Bowel and bladder control has not changed.
  •       MUSCULOSKELETAL: No back pains, joint pain, muscle pain, or stiffness of joints.
  •       HEMATOLOGIC: No history of bruising, bleeding, or anemia.
  •       LYMPHATICS: No history of splenectomy or enlargement of the lymph nodes.
  •       ENDOCRINOLOGIC: No reports of heat or cold intolerance. No reports of sweating. No polydipsia or polyuria.

Objective:

Physical exam: N/A

Diagnostic results: Toxicology reports indicates traces of Cannabis sativa

Assessment

Mental Status Examination:

The patient is well-groomed and dressed appropriately for the weather outside. She is clothed appropriately for her age. She has good hygiene. During the interview, the patient had a laid-back and obedient demeanor. She speaks clearly, with enough volume, at a regular tempo, and with a wealth of vocabulary. She seems dysphoric in her overall mood.

Observation reveals that the client is uneasy; she constantly moves and looks around the space. No reported cases of delusion exist. The patient is quickly distracted by other outside occurrences and is not totally engaged in the inquiries. She enquires about the wall decorations and the interviewer’s preference for travel. Her apparent flight of ideas is evidenced by the fact that she swiftly diverts the conversation from the current topic. She does not have any perception issues.

The patient is alert and oriented X4 (to person, time, place, and situation). She is having trouble concentrating; she cannot name the months of the year backward. She mentioned November and December but could not say whether June or July came next. She could recall all the numbers she was asked to repeat: 4, 6, and 9. Her short-term memory is still intact. She answered accurately that she had eaten oats, milk, and pancakes that morning, demonstrating that her memory for the recent past was outstanding. 

She remembered her favorite character from an animation she had watched in the past because her long-term memory was still intact. Her ability to reason abstractly was excellent. She correctly identified the book when asked to choose the odd item from bread, butter, and a book list. The fact that butter and bread were considered foods, while the book was not, was another strong argument for her belief that it was odd. The patient has no understanding of her condition. She made wise decisions. When asked what she would do if she discovered her dog stuck behind a door, she replied that she would contact her parents for assistance in releasing the dog.

Primary diagnosis

Major depressive disorder

The patient has not been happy lately and self-reported that she has been a little depressed. The parents also report that she is uninterested in attending the school plays. She also sleeps an average of 2 to 3 hours in 24 hours, indicating insomnia. The parents also reported that she had a loss of energy. She is also experiencing feelings of worthlessness and recurrent thoughts of death. All these symptoms point to a definite diagnosis of major depressive disorder. 

The DSM V TR requires that five or more of the definite symptoms of MDD exist in the same 2-week period and should indicate a change in functioning. One of the symptoms must be a loss of interest in activities or a depressed mood. The five symptoms that make the diagnosis pertinent are a depressed mood for most of the day, diminished interest, insomnia, loss of energy, feelings of worthlessness, and recurrent thoughts of death (American Psychiatric Association, 2022). All these criteria are indicative of Major Depressive Disorder.

Critical thinking process

My critical thinking considered several important factors while deciding on Major Depressive Disorder as the significant diagnosis. I carefully examined the client’s past, taking note of any history of self-harm or other depressive symptoms, including poor mood, feeling unworthy, and wanting to die. I also looked at the client’s psychosocial issues, such as their history of conduct disorder, drug use, and mental health illnesses in the family.

I could recognize a pattern of symptoms compatible with the diagnosis of Major Depressive Disorder by fusing these pieces of information and contrasting them with the diagnostic standards for this condition. I chose to diagnose the client with major depressive disorder using my critical thinking process to assess their presentation in the context of their psychosocial history and symptoms.

Differential Diagnoses

Substance-induced depressive disorder

Criteria A for this diagnosis requires that the client presents with a persistent and prominent mood disturbance characterized by a depressed mood or a diminished interest in all or almost all activities (American Psychiatric Association, 2022). She presents with a loss of interest in participating in school plays and admits that she is a little depressed, making this differential diagnosis probable. Criteria B requires that the evidence from the findings show that the client developed the symptoms due to withdrawal or after exposure (American Psychiatric Association, 2022). However, the client does not present with withdrawal symptoms despite the toxicology report showing that she had consumed cannabis sativa.

Borderline personality disorder

The client presents with unstable interpersonal relationships; she has a history of domestic violence against her brother and self-harm, which she engaged in 6 months ago. Medications had worsened her impulsivity. Her parents also believe that she has been hiding her medications because she thinks they slow her down and make her not think fast, showing instability in her self-image.

The diagnostic criteria for this condition require a history of identity disturbance and impulsivity in two potentially self-damaging areas; she is engaging in substance abuse and unprotected sex and has a history of self-mutilating behavior (Boland et al., 2022). She also feels empty as she says she is worthless and wants to die. All her symptoms meet the criteria for Borderline personality disorder as a differential diagnosis.

Disruptive mood dysregulation disorder (DMDD)

The client has a history of conduct disorder and domestic violence towards her sibling, probably because of anger outbursts. The history of taking citalopram worsened her irritability, aggression, and impulsivity, making DMDD to be a potential differential diagnosis. Severe recurrent temper outbursts three or more times per week, a hallmark of DMDD, are absent. Although the client has a history of violence, irritability, and conduct disorder, the evidence does not particularly point to severe recurrent temper outbursts as defined by the criteria for DMDD.

Reflection

Working on this case study has taught me more about the intricacy of mood disorders and how they affect a person’s life. This case demonstrated the value of a thorough evaluation that takes the client’s history, family relationships, and consumption of drugs into account. I have also understood the importance of a therapeutic alliance in fostering openness and trust. I would ensure regular interaction and collaboration with the interdisciplinary team to understand the client’s needs comprehensively.

I would prioritize continuing my education in mood disorders, particularly the diagnostic standards and research-supported treatments. To effectively serve the client, I would also focus on developing my therapeutic communication and crisis management abilities. Overall, this experience has highlighted the necessity for a caring and tailored approach to care and the constant learning process.

Working with this client has increased my awareness of the ethical and legal concerns surrounding providing for them. Handling these issues while upholding the client’s dignity, liberty, and privacy is critical. Along with confidentiality and informed consent, it is essential to carefully manage issues like required reporting of domestic abuse and self-harm risk while maintaining the client’s best interests in mind (Ventura et al., 2020).

To provide comprehensive care, it has become essential to comprehend the social determinants of health. Interventions should assist the client’s passage to adulthood and address the educational requirements, given that she is a senior in high school. Their ethnicity may also impact their cultural values and health-seeking habits, necessitating culturally competent treatment to build rapport and successful communication.

Disease prevention and health promotion strategies should be adapted to the client’s risk factors. Substance abuse treatment options, access to contraception, and education about safer sexual practices are all necessary because of substance use and unsafe sexual behaviors. Given the history of conduct disorder, interventions emphasizing anger management and coping mechanisms may be advantageous.

It is crucial to consider any financial limitations that can limit the client’s access to services and treatment while also considering their socioeconomic background. Collaboration with community organizations and social service agencies could offer extra assistance. A supportive atmosphere can be fostered, and family difficulties, such as the reported domestic abuse, can be addressed by including the client’s family in the care process.

Reflecting on this incident, I recognize the need for a thorough, patient-centered strategy. It necessitates a thorough awareness of risk factors, socioeconomic determinants of health, and legal/ethical issues. I may enhance the client’s general well-being and enhance the results of their health therapies by critically assessing these elements.

NRNP 6635 Case History Reports References

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787

Boland, R. J., Verduin, M. L., & Ruiz, P. (2022). Kaplan & Sadock’s synopsis of psychiatry (12th ed.). Wolters Kluwer.

Ventura, C. A. A., Austin, W., Carrara, B. S., & de Brito, E. S. (2020). Nursing care in mental health: Human rights and ethical issues. Nursing Ethics, 28(4), 096973302095210. https://doi.org/10.1177/0969733020952102

Also Read: Borderline Personality Disorder Sample Paper