Comprehensive Clinical Case
Study Presentation
Lisa Agnew, BSN
NUR 7611
Wright State University
Case Study
AL a 24-year old mother of two children ages 2 and five months old presented to the
out patient clinic with her boyfriend with “depression, anger, impatience, and having
sleeping difficulties” that have gotten progressively worse over the last six months.
AL explains she “does not feel good and never feels good and lacks energy”. She
finds herself isolating herself in her room watching TV or sleeping to attempt to
alleviate her feelings of depression. AL’s responses appeared negative with splitting
defense mechanisms present. The symptoms are affecting AL’s ability to take care of
her children, attend college, and continue employment at Pizza Hut. AL’s boyfriend
reports that she cries often, is not eating, exercising or reading books as she used to.
He also mentioned her frequent threats of not wanting to live, but he thought she
said this because she was upset at him and the kids. AL reports her mother
encouraged her to seek counseling and psychiatric services.
Chief Complaint/ History of
Present Illness
• AL’s chief complaint: “increased depression,
irritability, and anger” over the last six months.
• Her usual coping mechanisms of reading, and
exercising have not been effective.
• She has had intermittent feelings of depression
over the last eleven years.
Medical History
AL’s medical history is positive for atrial fibrillation (Afib) and hypotension. She was diagnosed with atrial
fibrillation five years ago and she takes Metoporol 25mg
by mouth every day for A-fib. She currently is also taking
Depro-Provera intramuscular every three months for
birth control prevention. She has had two normal
pregnancies and deliveries. She does not have any
significant surgical history or allergies.
Psychiatric History
“I have had depression my whole life”. She denies any previous
hospitalizations for psychiatric mental illness. AL has seen a
psychiatrist for depression at age of 13-18. She stopped her treatment
of Zoloft and Depakote without consulting her psychiatrist, but
returned to a family physician with continued c/o depression at the
age of 21. At that time she was prescribed Welbutrin. She stopped
treatment two years ago. The medications “make her feel like a
zombie or crazy”. She denies taking or using any over the counter or
prescriptive medications for depression or psychiatric illness.
Family History
AL has three sisters and five brothers. Her parents were
divorced when she was five years old. She denies
physical, emotional, or sexual abuse from her parents.
Her mother and youngest brother has diabetes, asthma,
hypothyroidism, and depression. Her father and oldest
brother as has a history and present problem with
alcoholism. Her middle brother committed suicide when
she was 13.
Social History
AL has never been married. She has had at least seven different male, one
female partners with unprotected sex. Her first relationship, father of her 2
year old, was physically and emotionally abusive. After leaving the
relationship she began having nightmares. She currently lives with her
boyfriend and two children. Her current boyfriend is the father of her fivemonth-old son. They often fight, but he is not verbally or physically abusive
toward her. AL has lived in at her current address for about six months. AL
has a GED, and is enrolled in nursing assistant classes, and employed at Pizza
Hut. She calls off work ad school frequently. She often refuses to get out of
bed, take a shower, grocery shop, cook, or do laundry.
Substance History
She drinks 2-3 beers with 2-3 shots of liquor 1-2 times a
month on weekends with intent to become intoxicated.
Her last use was this past weekend. AL began alcohol
and drug use at age 12. She has used cocaine, cannabis,
heroin, molly, and crack. Her last use was in 2009 when
she found out she was pregnant. She currently smokes
one pack of cigarettes and drinks 3- 16 ounces of
Mountain Dew a day.
Focused Physical
General: She is of medium build, casually dressed, clean, and appearing her given age.
Weight : 150 pounds Height: 5’4
Vitals: 108/62 b/p, 102 apical, irregular, 18 respirations, oral temp of 98.7, SPO2 n 90%
Skin/Hair/Nails: Smooth,dry without lacerations or eruptions.
HEENT: She denies ocular, auditory, or olfactory dysfunction. Her pupils are round and reactive to
light, and with symmetrical movement.
Neck: AL denies throat pain, trachea is midline, without thyroid enlargement or venous distention.
Chest: AL denies cough, has symmetrical respirations
CV: Her heart sounds are without bruits or murmurs.
GI/GU: Abdomen is flat without visual masses. She denies GI or GU dysfunction.
Neurologic and musculoskeletal: Without deviation, equal movement and facial asymmetry, steady
gait and equal hand grasp. No noted tremors, numbness, atrophy, spasticity or weakness.
Mental Status Assessment
•
General Appearance: She is dressed in appropriate clothing for the weather.
She appears clean but somewhat disheveled. Her hair is not
combed and appears oily. AL appears fatigued with dark circles noted
under her eyes
•
Attitude/Behavior: She is calm and cooperative with answering questions.
•
Eye Contact: intermittent eye contact when spoken to but frequently looks down
at the floor when she speaks.
•
Speech: Soft, low volume, and slow to respond to questions at times.
•
Psychomotor: Slow gait, slumped posture , limited slow movement
•
Mood: “ very sad, irritated, frustrated and angry”. She rates her depression a 7 on
a scale of 0-10 with 0 being no depression. She rates irritability a 7, and
anger a 5 on the same scale.
•
Affect: Blunted Affect and Mood are congruent.
•
Thought Content: Episodic suicidal thoughts with a vague plan to ingest Tylenol
when her boyfriend and children are not home, but she
does not have a clear timeline or planned intent. She denies homicidal
ideation.
•
Thought processes: Logical and organized, complains of racing thoughts at
night preventing her from sleeping.
•
Sensorium: intact with an ability to spell “world” backwards.
•
Cognition: AL can correctly complete serial number testing and answer abstract
thinking questions. Cognitive skills required extended time to complete.
Difficulty concentrating and often forgets things with periods of short-term
memory loss. She explains she often feels paranoid that people talk about
her and watch her everywhere she goes. She sees ghost and hears balls
bounce in her home at least three times a week at night for the last two
weeks. She denies active visual or auditory hallucinations .She is oriented
to person, place, time, and situation
•
Insight/ Judgment: Poor
Differential Diagnosis with
Rationale
1.
Alcohol Dependence (history and current use of alcohol)
2.
Schizophrenia (current hallucinations and delusional behaviors)
3.
Bipolar II Disorder (current and history of depression),
4.
Panic Disorder with Agoraphobia (current isolation, refusal to go to grocery
store, and heart palpations)
5.
Major Depressive Disorder (anhedonia and current history of depression)
6.
Dysthymic Disorder (long history of depression)
7.
Generalized Anxiety Disorder (history of heart palpations and isolation)
8.
Posttraumatic Stress Disorder (history of physical abuse with nightmares)
9.
Primary Insomnia (current dysfunction of sleeping pattern)
Diagnostic Test
Rationale
TSH, T3, T4
AL has a family history of hypothyroidism and
displays symptoms of depression, fatigue,
palpations, and memory impairment.
Oxygen level (SPO2)
AL has symptoms of insomnia and SPO2 was 90%.
Urinalysis
AL exhibits slight cognitive delay.
Urine Pregnancy test
AL is of childbearing age and has fatigue.
Urine drug screen
AL has a history of substance abuse, hallucinations,
depression, palpations, and memory impairment.
Blood Alcohol
AL has irritability, memory impairment, and history
of alcohol abuse
Liver Function Test LFT, ALT, AST
AL has a history of alcohol and substance abuse, use
of prescriptive drug use, and multiple unprotected
sexual partners
EKG
AL does exhibit cardiac irregularity, and has a history
of A-Fib, records will be requested from her
cardiologist, if unavailable, EKG will be obtained.
CBC
AL has symptoms of depression and fatigue.
Finger Stick Glucose Testing
AL has a family history of diabetes
Prioritized Plan
• Diagnosis
• Goals of treatment
• Interventions: Psychotherapy, psychosocial
interventions and pharmacotherapy
• Evaluation of treatment: Follow up
Diagnosis
• Axis I
1.
296.34 Major Depressive Disorder, Recurrent, Severe with
Psychotic Features
2.
303.90 Alcohol Dependence
3.
309.81 Posttraumatic Stress Disorder.
• Axis II
(Rule out) 301.83 Borderline Personality Disorder
• Axis III
Hypotension and Arial Fibrillation
Goals
• Reduce symptoms (fatigue, depression, insomnia, anxiety)
• Reduce risk of suicide
• Improve activities of daily living and instrumental activities of daily
living (cooking, cleaning, driving)
• Improve coping skills
• Prevent recurrence
• Promote recovery
• Prevent relapse
• Decrease adverse effects on the family (fighting, break ups)
Interventions
• Cognitive Behavioral Therapy (CBT) is useful in
individuals with Depression, PTSD, and
Borderline Personality.
• Interpersonal Relationships Therapy (IRT) is
useful with PTSD.
• Motivational Enhancement Therapy (MET) is
useful in with substance abuse and dependence.
Other Interventions
Health Promotion Activities
Psychosocial interventions
To promote Self-Care activities, new coping skills,
and change dysfunctional thinking.
• Walk twice a week with her boyfriend
• Teach diet/hygiene/sleep importance
• Aroma Therapy/ Breathing Techniques
Medications
Pharmacotherapy Treatment
• Zoloft 50mg PO once a day for depression,
PTSD, and anger symptoms.
• Vistaril 25mg PO three times a day PRN for
anxiety insomnia, and racing thoughts.
Evaluation: Follow-Up
• AL should have a routine physical assessment and
laboratory blood work initially and yearly unless symptoms
indicate to be completed sooner. (Review labs)
• Individual Counseling Services (Review progress notes)
• AL is to return to the outpatient clinic in four weeks (Are
symptoms better/ Goals met?)
• Screening tools: Beck Depression Inventory and the Risk of
Suicide Questionnaire
References
•
American Psychiatric Association. (2000). Diagnostic and Statistical Manual of
Mental Disorders (4th ed.). Washington, DC.
•
Doebbeling, C. (2013). Medical Assessment of the Patient with Mental Symptoms.
Retrieved from:http://www.merckmanuals.com/professional/
psychiatric_disorders/approach_to_the_patient_with_mental_symptoms/
medical_assessment_of_the_patient_with_mental_symptoms.html DSMIV
•
Perese, Eris Field (2012). Psychiatric advanced practice nursing: A biopsychosocial
foundation for practice. Philadelphia, PA: F.A. Davis.
•
Nauert, R. (2014). Family History Predicts Risk of Mental Disorders. Retrieved
from: http://www.medicalcriteria.com/criteria/