Grand Rounds Discussion: Complex Case Study Presentation
This week you participate in the final of three clinical discussions called grand rounds. When it is your week to present, you will create a focused SOAP note and a short didactic (teaching) video presenting a real (but de-identified) complex patient case from your practicum experience.
You should have received an assignment from your Instructor letting you know which week of the course you are assigned to present. Any student who has not yet presented should present this week.
To prepare:
Review this week’s Learning Resources and consider the insights they provide. Also review the Kaltura Media Uploader resource in the left-hand navigation of the classroom for help creating your self-recorded Kaltura video.
Select an older adult patient from your clinical experience that presents with a significant concern. Create a focused SOAP note for this patient using the template in the Resources. All SOAP notes must be signed, and each page must be initialed by your Preceptor. When you submit your SOAP note, you should include the complete SOAP note as a Word document and PDF/images of each page that is initialed and signed by your Preceptor. You must submit your SOAP note using SafeAssign.
Please Note: Electronic signatures are not accepted. If both files are not received by the due date, Faculty will deduct points per the Walden Late Policies.
Then, based on your SOAP note of this patient, develop a video case study presentation. Set aside time to practice what you will say beforehand and ensure that you have the appropriate lighting and equipment to record the presentation.
Your presentation should include objectives for your audience, at least 3 possible discussion questions/prompts for your classmates to respond to, and at least 5 scholarly resources to support your diagnostic reasoning and treatment plan.
Video assignment for this week’s presenters:
Record yourself presenting the complex case study for your clinical patient. In your presentation:
- Dress professionally in a lab coat and professionally present yourself.
- Display your photo ID at the start of the video when you introduce yourself.
- Ensure that you do not include any information that violates the principles of HIPAA (i.e., do not use the patient’s name or any other identifying information).
- State 3-4 objectives for the presentation that are targeted, clear, use appropriate verbs from Bloom’s taxonomy, and address what the audience will know or be able to do after viewing.
- Present the full complex case study. Include chief complaint; history of present illness; any pertinent past psychiatric, substance use, medical, social, family history; most recent mental status exam; current psychiatric diagnosis including differentials that were ruled out; and plan for treatment and management.
- Report normal diagnostic results as the name of the test and “normal.” (rather than specific value). Abnormal results should be reported as a specific value.
- Pose 3 questions or discussion prompts, based on your presentation, that your colleagues can respond to after viewing your video.
- Be succinct in your presentation, and do not exceed 8 minutes. Specifically address the following for the patient, using your SOAP note as a guide:
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 their mental status examination results. What were your differential diagnoses? Provide a minimum of 3 possible diagnoses and why you chose them. List them from highest priority to lowest priority. What was your primary diagnosis, and why? Describe how your primary diagnosis aligns with DSM-5 diagnostic criteria and is supported by the patient’s symptoms.
Plan: What was your plan for psychotherapy (include one health promotion activity and patient education)? What was your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.
Reflection notes: What would you do differently with this patient if you could conduct the session again? If you can follow up with your patient, explain whether these interventions were successful and why or why not. If you were not able to conduct a follow-up, discuss what your next intervention would be.
A note on grading:
Presenters: Review the Grand Rounds Presenter Rubric to ensure you meet the scoring criteria.
Participants: Review the Grand Rounds Participant Rubric to ensure you meet the scoring criteria.
Solution
Week (enter week #): (Enter assignment title)
Student Name
College of Nursing-PMHNP, Walden University
PRAC 6675: PMHNP Care Across the Lifespan II
Faculty Name
Assignment Due Date
Presentation Objectives:
- To identify the clinical presentations of a patient with multiple mental illnesses.
- Identify if the most appropriate medication for a patient with multiple mental conditions.
- To analyze the best psychotherapeutic approaches for a patient with multiple mental disorders.
Patient Initials: G. L. Gender: Male Age: 73 yrs Race: Caucasian Date: 16/05/2021
Subjective:
CC (chief complaint): “My partner has depression, anxiety, and passive death wish.”
HPI: G. L., a 73-year-old, domiciled, Cucassian male, reports to the clinic accompanied by his partner Paul Rocha. As reported by Rocha, G. L. has been presenting with behavioral symptoms including social withdrawal, anxiety, depressed mood, anhedonia, passive death wish, suicidal ideation. These symptoms began 12 months ago. He was admitted to Inova Loudoun Psychiatric Hospital for one day with similar behavioral problems. His primary diagnosis at the time of discharge was major depressive disorder with psychotic features (paranoia).
The doctor prescribed Sertraline 100 mg p.o. daily, bupropion XL 300 mg p.o. daily, and aripiprazole 10 mg p.o. daily. These drugs caused a slight improvement in suicidal ideation then the symptoms returned. According to Rocha, G. L. had to visit the emergency department at Inova Alexandria again when his symptoms worsened following the first discharge. He complained of anxiery and depression that were characterized by helplessness and hopelessness.
Other symptoms displayed by G. L. at the time of emergency visit were diminished suicidal thoughts and a passive death wish. Following a comprehensive psychiatric review, the doctor discovered that G. L. has multiple behavioral symptoms including; decreased energy, decreased motivation, diminished concentration, depressed mood, anxiety/disphoria, anhedonia, poor appetite, significant weight loss, and passive death wish/suicidal ideation. Rocha reports that the doctor prescribed electroconvulsive therapy (ECT) and G. L. refused to receive the intervention.
Substance Current Use: G. L. has used alcohol with a history of no withdrawals. He denies alcohol consumption currently. G. L. has never smoked and denies using smokeless tobacco. He denies detox history, rehab history, and legal repercussions.
Medical History:
- Current Medications:
Aripiprazole (Abilify) tablet : 10 mg orally daily
Bupropion XL (Wellbutrin XL) tablet : 300 mg orally daily
Finasteride (PROSCAR) tablet : 5 mg orally daily
Metformin (Glucophage) tablet : 1,000 mg orally twice daily with meals
Phenazopyridine (Pyridium) tablet : 200 mg orally 3 times daily
Rosuvastatin (Crestor) tablet : 5 mg orally daily
Sertraline (Zoloft) tablet : 100 mg orally daily
- Allergies: L. develops chemical hepatitis when he uses Erythromycin. He also develops skin rashes when he uses Sulfa antibiotics. Simvastatin use causes muscle cramps.
- Reproductive Hx: None reported.
Family History:
None reported.
ROS:
- GENERAL: G. L. looks healthy but depressed. He has poor appetite and reports a significant weight loss of approximately 50 pounds. He appears to be overwhelmingly anxious.
- HEENT: Head: Denies head injrury, Eyes: Denies blood vision or visual loss, Ears: Denies hearing loss, Nose: Denies runny nose, nasal congestion, or sneezing, Throat: Denies sore throat.
- SKIN: Denies itching or skin rashes.
- CARDIOVASCULAR: Denies chest discomfort or chest pain.
- RESPIRATORY: Denies cough or shortness of breath.
- GASTROINTESTINAL: Reports constipation.
- GENITOURINARY: Urinary incontinence with placement of Foley catheter since October 2020.
- NEUROLOGICAL: Denies dizziness, headache, or numbness of the extremities.
- MUSCULOSKELETAL: Reports general body weakness.
- HEMATOLOGIC: Denies anemia, excessive bleeding, or other blood disorders.
- LYMPHATICS: Denies enlarged nodes.
- ENDOCRINOLOGIC: Denies abnormal night sweats, frequent urination, or enlarged thyroid.
Objective:
Diagnostic results: Patient symptoms were evaluated against the Diagnostic and Statistical Manual of mental disorders version 5 (DSM-5) (American Psychiatric Association, 2013). Results revealed decreased energy, decreased motivation, diminished concentration, depressed mood, anxiety/disphoria, anhedonia, poor appetite, significant weight loss, and passive death wish/suicidal ideation.
Laboratory tests were conducted to determine the concentration of magnesium in blood and to establish hemolysis index. Low blood magnesium concentration is associated with severe mental illnesses, especially depression in older adults (Botturi et al., 2020). Magnesium concentration was 1.8 mg/dl. Hemolysis index is a measure of hemoglobin concentration in blood due to the rapture of red blood cells, usually in hemolytic anemia.
A common presenting symptom of hemolytic anemia in older adults is cognitive impairment (Badireddy & Baradhi, 2020). EKG was performed to establish cardiac performance. Evidence indicates that some mental illnesses such as anxiety and depression can develop after cardiac events that affect cardiac performance (Polcwiartek et al., 2021; Centers for Disease Control and Prevention, 2020). Results revealed no evidence of cardiac issues. Suicide Risk Assessment has revealed evidence of suicide thoughts.
Assessment:
Mental Status Examination:
L. is a 73-year-old Caucassian male who appears to be in good health. G. L. does not appear chronological age. He is poorly groomed and appears older than his stated age. He is lying comfortably in bed and he is slightly disheveled. G. L. is calm, cooperative, keeps eye contact, and is unable to sit up. He lies on the bed throughout the interview. There is evidence of psychomotor retardation. His muscles are grossly intact. G. L.’s speech is clear and spontaneous, rate and rhythm is normal, volume is soft, and tone is normal. He has a depressed mood.
His affect range is constricted, appropriate to thought content, and stable with normal intensity. G. L.’s thought process is coherent and logical. He is generally goal-oriented. There is no evidence of delusional thoughts. G. L. reports helplessness, hopelessness, and feelings of guilt. He also reports suicidal thoughts. There is no evidence of homicidal or violent thoughts. G. L. denies dissociative perceptions, hallucinations, or illusions.
There is evidence of poor insight and poor judgment. Level of consciousness is intact. He is perfectly oriented to self, place, and time. Recent memory is poor. Poor remote memory is evidenced. Attention, concentration, language, repetition, and recognition are intact. His fund of knowledge is poor.
Diagnostic Impression:
Differential diagnoses:
- F 33.2 Major depressive disorder, recurrent, severe without evidence of psychotic features; plus F 41.1 generalized anxiety disorder, by history
- Major depressive disorder alone
- Generalized anxiety disorder alone
F 33.2 Major depressive disorder, recurrent, severe without evidence of psychotic features; plus F 41.1 generalized anxiety disorder, by history
The primary diagnosis for G. L’s symptoms is major depressive disorder that co-occurs with generalized anxiety disorder. The diagnosis has been chozen because G, L.s’ symptoms math the DSM-5 criteria for the two named mental illnesses. As outlined in the manaual, the presence of major depressive disorder is confirmed when a person has at least five of a number of symptoms including; depressed mood , disinterest in activities, significant weight loss or weight gain, sleep disturbance, fatigue/decreaed energy, feelings of worthlessness/hopelessness, lack of concentration, lack of motivation, and recurrent thoughts of death.
Additional symptoms that a person must possess for major depressive disorder to be confirmed include; the behavioral symptoms must cause impairment in important areas of functioning, the symtoms are not caused by other factors such as medication, bereavement, or substance use, and they do not meet the criteria or manic episodes (American Psychiatric Association, 2013).
The diagnosis of generalized anxiety disorder is confirmed when the patient meets a number of diagnostic criteria. The criteria include, excessive worry over a number of things or events, inability to control excessive worry, the patient presents with at least three symptoms among them including; irritability, muscle tension, restlessness, fatigue/loss of energy, difficulty concentrating and sleep disturbance. Additionally, the patient should report clinically significant impairment due to the named symptoms. The symptoms must not be attributed to other factors such as medication use, substance, abuse, or a post-traumatic stress disorder (American Psychiatric Association, 2013).
L. is a 73-year-old Caucassian, domiciled male with no previous psychiatric history. He complains of multiple behavioral symptoms including dysphoria, increased anxiety, depressed mood, poor appetite, weight loss, low energy, decresed concentration, anhedonia, lack of motivation, feelings of hopelessness, intermittent suicidal ideation, and a passive death wish. He has been receieving consistent treatment as an outpatient and was hospitalized once in September 2020.
Prescribed medications have not caused an improvement in symptoms. Current diagnosis indicates that G. L. is severely depressed without clear evidence of psychotic features. His symptoms match the DSM-5 diagnostic criteria for a major depressive disorder that co-occurs with a generalized anxiety disorder (American Psychiatric Association, 2013). This rules out the presence of a major depressive disorder and a generalized anxiety disorder occurring in isolation.
Major depressive disorder alone
- L.s symptoms match the DSM-5 diagnostic criteria for major depressive disorder described in the paragraph above. However, the patient’s partner has reported that he also presents with dysphoria, low energy/fatgue, increased anxiety, and decreased concentration. This indicates that G. L. has another mental condition that is co-occuring with major depressive disorder. Therefore, it is inappropriate to conclude that he has major depressive disorder alone.
Generalized anxiety disorder alone
- L.s symptoms match the DSM-5 diagnostic criteria for generalized anxiety disorder described in the paragraph above. In addition to these symptoms, the patient also has depressed mood, poor appetite, weight loss, low energy, decresed concentration, anhedonia, lack of motivation, feelings of hopelessness, intermittent suicidal ideation, and a passive death wish. This indicates that G. L. has another mental condition that is co-occuring with generalized anxiety disorder. Therefore, it is inappropriate to conclude that he has generalized anxiety disorder alone.
Reflections:
After reviewing the patient’s symptoms together with my preceptor, we have agreed that he has an acute risk to self due to suicidal thoughts. Again, G. L. is unable to take good care of himself in the community owing to the lack of a proper support system. Therefore, he requires inpatient hospitalization. From this case, I have learned that older adults can present with multiple mental illnesses which require careful evaluation, diagnosis, and treatment. If I were the provider who met the patient first, I would conduct a comprehensive assessment to make an accurate diagnosis before administering any medications.
Case Formulation and Treatment Plan:
- Addmit the patient for further evaluation and treatment
- Stabilize the patient with psychopharmacologic and psychopharmacologic interventions
- Psychopharmacologic treatment: Aripiprazole 10 mg p.o. every morning, Taper bupropion XL to 150 mg p.o. daily, Initiated mirtazapine 7.5 mg p.o. nightly, Taper sertraline to 50 mg p.o. every morning (Avasthi & Grover, 2018).
- Non-pharmacologic treatment: Provide psychoeducation (individual therapy) daily (Carlat, 2017).
- Alternative therapy: Provide psychoeducation (group therapy) involving significant others (Carlat, 2017).
- Referral: Refer the patient to a primary care physician for further physiological evaluation.
- Follow-up: Conduct follow-up after every 4 weeks to monitor patient’s progress.
Rationale: The rationale for the chosen treatment or management plan is to ensure that G. L. experiences an improvement in symptoms and he is able to attain good quality of life (Avasthi & Grover, 2018).
Discussion Prompts
- Do you think social support from family members and significant others can help to improve G. L.’s symptoms?
- Describe members of interprofessional teams that you would involve in the care of the patient to ensure better health outcomes.
- Considering the patient’s age, would individual psychotherapy produce better outcomes when compared to a group therapy?
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
Avasthi, A., & Grover, S. (2018). Clinical practice guidelines for management of depression in elderly. Indian Journal of Psychiatry, 60(Suppl 3), S341–S362. https://doi.org/10.4103/0019-5545.224474
Badireddy, M., & Baradhi, K. M. (2020). Chronic anemia. Treasure Island (FL): StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK534803/
Botturi, A., Ciappolino, V., Delvecchio, G., Boscutti, A., Viscardi, B., & Brambilla, P. (2020). The role and the effect of magnesium in mental disorders: A systematic review. Nutrients, 12(6), 1661. https://doi.org/10.3390/nu12061661
Carlat, D. J. (2017). The psychiatric history and the psychiatric review of symptoms. The psychiatric interview (4th ed. Ch 14-18 & Ch 23-24). Wolters Kluwer.
Centers for Disease Control and Prevention. (2020). Heart disease and mental health disorders. https://www.cdc.gov/heartdisease/mentalhealth.htm
Polcwiartek, C., Atwater, B. D., Kragholm, K., Friedman, D. J., Barcella, C. A., Attar, R., Graff, C., Nielsen, J. B., Pietersen, A., Søgaard, P., Torp-Pedersen, C., & Jensen, S. E. (2021). Association between ECG abnormalities and fatal cardiovascular disease among patients with and without severe mental illness. Journal of the American Heart Association, 10(2), e019416. https://doi.org/10.1161/JAHA.120.019416.