Critical reflection of your growth and development duri

· Reflect on the three (3) most challenging patients you encountered during the practicum experience. What was most challenging about each?

· What did you learn from this experience?

· What resources did you have available?

· What evidence-based practice did you use for the patients?

· What new skills are you learning?

· What would you do differently?

· How are you managing patient flow and volume? 

Communicating and Feedback

· Reflect on how you might improve your skills and knowledge and how to communicate those efforts to your Preceptor.

· Answer the questions: How am I doing? What is missing?

· Reflect on the formal and informal feedback you received from your Preceptor. 

Week (#5): Case Presentation: Bipolar Disorder

Babatunde T Alli

College of Nursing-PMHNP, Walden University

NRNP 6635: Psychopathology and Diagnostic Reasoning

Faculty Name

Jan 21,2022

CASE STUDY

Name: Monica Dennis

Gender: Female

Age: 35-years-old

Height is 175, Weight is 69kg, BMI IS 22.5. Vital Signs: BP-129/73, T-98.1, R-20, P-86. Denies pain upon assessment

Background: Monica Dennis was born in New York City but later moved to ST. Louis, MO with her mother upon the death of her father who allegedly commit suicide by hanging.

HX: Monica is a 35-year-old AA with history of mental illness and multiple psychiatric hospitalization. She was referred to Touchette Regional hospital for voluntary admission by her psychiatrist. Client stated that “ I am ready to go and see my dad , I want to call it the end” She is also exhibiting symptoms such as audio and visual hallucinations, severe depression, feeling of hopelessness, worthlessness, agitation, anger outburst, isolating, and insomnia. Disorder that causes significant distress and interferes with normal daily routine. Exhibit mood swings and irrational behavior that is detrimental to her physical and mental wellbeing. Also, she has suicidal ideation with plan to take multiple pills out of her prescriptions.

Subjective:

CC (chief complaint): Client stated that “ I am ready to go and see my dad , I want to call it the end”.

HPI: Monica is a 35-year-old AA with history of mental illness and multiple psychiatric hospitalization. She was referred to Touchette Regional hospital for voluntary admission by her psychiatrist for suicidal ideation with plan. Patient did not currently have any gun and did not have access to gun. Patient denied ever wanting to destroy property or wanting to hurt other people. Client stated that “I am ready to go and see my dad, I want to call it the end” She is also exhibiting symptoms such as audio and visual hallucinations, severe depression, feeling of hopelessness, worthlessness, agitation, anger outburst, isolating, and insomnia. Disorder that causes significant distress and interferes with normal daily routine. Exhibit mood swings and irrational behavior that is detrimental to her physical and mental wellbeing. Also, she has suicidal ideation with plan to take multiple pills out of her prescriptions.

Past Psychiatric History: Patient was diagnosed and admitted for Major Depression with Suicide ideation at St. Mary hospital behavioral health, patient also report being admitted to Collinsville memorial hospital 7 months ago for psychosis.

· General Statement: Patient was first diagnosed with severe depression when she failed classes in her high school and wanted to kill herself. Patient was on medications but will take leave to different states with boyfriend where she will miss taking her meds and ends up being hospitalized.

· Caregivers (if applicable): Patient mother has played and still playing a significant role in making sure patient is safe and able to take care on self.

· Hospitalizations: This is the seventh psychiatric hospitalization, adherent is a major factor in patient’s case.

· Medication trials: Lithium, Depakote and Zoloft

· Psychotherapy or Previous Psychiatric Diagnosis: Major Depressive Disorder.

Substance Current Use and History: Patient has no history of substance abuse but smokes half a pack of cigarette daily. UDS positive for cocaine, opiate, meth amphetamines but positive for copd.

Family Psychiatric/Substance Use History: Monica’s mother has two other male children aged 21 who smokes cannabis relentlessly and was terminated before completing high school. Monica’s brother who is 27-year-old was a college dropout who drives trucks and a known alcoholic who has relapsed many times until his drivers’ licenses was revoked, many DUI’S. Patient has been hospitalized multiple times due to depression and sometimes alternate with manic episodes. Monica has always been non-compliance and always go back and forth to the hospital. Per previous medication history patient is on Lithium, Depakote and sertraline.

Psychosocial History: Patient report being single, children stays with her mother, she lost her job several years ago and no one would re-employ her because she’s on certain medications.

Medical History: Patient denied having any critical medical condition, CBC, CMP lipid panel, TSH level and Creatinine Clearance were all normal

· Current Medications: Lithium, Depakote, and Zoloft.

· Allergies: No known food or drug allergies

· Reproductive Hx: Patient has three daughters 9, 7, and 5

ROS:

· GENERAL: Height is 175, Weight is 69kg, BMI IS 22.5. Vital Signs: BP-129/73, T-98.1, R-20, P-86. Denies pain upon assessment

· HEENT: Head is symmetric, Normocephalic , pupil are rounds equal , reactive to light and accommodation. Ear, Nose and Throat: all clear. Neck is supple, no jugular vein distention. No thyroidmegally

· SKIN: Normal skin Turgor

· CARDIOVASCULAR: Regular heartbeat, no murmur or gallop heard upon auscultations. S1, S2 regular.

· RESPIRATORY: Lungs are clear upon auscultations, chest normal regular breathing, no labor breathing observed.

· GASTROINTESTINAL: Abdomen soft and non-tender. No organomegaly, Bowel sounds presents at four quadrants, surgical scare at the lower middle quadrant

· GENITOURINARY: Patient able to urinate without difficulty, no burning or painful urination

· NEUROLOGICAL: Cognitively impaired

· MUSCULOSKELETAL: physically normal

· HEMATOLOGIC: All blood labs normal

· LYMPHATICS: no abnormality mentioned

· ENDOCRINOLOGIC: No abnormality observe.

Objective:

Physical exam: Patient walks into the interview without any assistance, patient is physically energetic. Height is 175, Weight is 69kg, BMI IS 22.5. Vital Signs: BP-129/73, T-98.1, R-20, P-86. Denies pain upon assessment

Diagnostic results: Upon review of the data presented to me at the clinic as at time of evaluation and assessment; WBC 9.8, HGB 14.9, HMTC 34.5, PLATELETS 379, BUN 9, Creatinine 0.6.Glucose 121, Calcium 10.5, LDL 46. HDL 38. Patient is Covid-19 negative with PCR antigen test.

Assessment: Upon assessment patient is alert and oriented to person, place, time and situation, guarded and snobby at the beginning of the interview.

Mental Status Examination: Appearance normal (Patient is appropriate for stated age) Eye Contact: Minimum eye contact noted, Hygiene: Patient is somehow untidy, needs improvement with Hygiene. Psychomotor Activity: No tremor, no agitations observed. Attention and Concentration: Patient is attentive with minimal concentration observed. Speech: Patient speaks at a fast pace, with mildly loud volume, pressured at most times upon asking questions. Thought process is disorganize with tangential hallucinations, thought content: Patient reports command and auditory and observed with responses tom internal stimuli. Mood: Patient is guarded, anxious , hallucinating and labile. Affect: flat. Patient is still endorsing suicidal ideation with plan, denies delusion, denies homicidal ideations. Patient insight is poor, and she is non-compliance with medication.

Major Diagnosis

Bipolar Disorder

Differential Diagnoses:

Anxiety

Mania

Major depressive disorder

Medication non-compliant

Tobacco (Nicotine) addiction Disorder

Reflections:

Saddock et al.,(2015) Claims that mood disorder (Major depressive disorder) is the most common type of psychiatric illness with prevalence of 5-17%. Bipolar disorder on the other hand has the milder prevalence of less than 1%percent which is randomly distributed among various types of bipolar disorder. Types of bipolar disorder is determined by rate of severity in the Manic episodes. The imbalance of Neurotransmitters such as serotonin, epinephrine, norepinephrine, responsible for low mood and Dopamine is responsible for manic behavior and alternating between the two disorders made it bipolar disorder (Saddock et al.,2015).

According to DSM-V this patient is qualify for this diagnosis because the criteria for DSM are met such as depressive episodes that last more than 2 months alternating with a period of abnormal elevated mood, irritability, increased activity, replacing night sleep with energetic activities, euphoric, excessively cheerful, grandiose, and possibly hallucinations, and with or without suicide ideations. When these symptoms went on for 1 week or 7days alternating with major depressive episode is bipolar I disorder. When the manic episodes become less like 4 days it is hypomanic episode and it is bipolar II. Cyclothymic disorder : when patient is presented with manic symptoms for 2years or 1 year for children and adolescent but there had been many hypomanic symptoms that are not enough to meet the requirement of manic or hypomanic episode and the major depressive disorders symptoms are no longer enough to meet the diagnosis of major depression, then this is called Cyclothymic disorder (APA, DSM-V, 2013). Dysthymic Disorder: Continuous depressive mood for 2 year or more than 1 year for children but not met with other diagnosis criteria for cyclothymia or major depressive disorder.

Differential diagnosis is Anxiety disorder- Patient is anxious and fear that his life is slow he lost his job and family are neglecting him gradually. Major depression: Patient has dysthymia (long time episode of sad mood or depressed mood), Insomnia or hypersomnia is present, lack of energy and fatigue is present within those periods, poor concentration and difficulty making good judgment. Mania, Tobacco (Nicotine) addiction disorder Patient smokes half a pack of cigarette a day and it is also very addictive , and Medication non-compliant.

References

American Psychiatric Association. (2013). Bipolar and related disorders. In Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author. doi:10.1176/appi.books.9780890425596.dsm03

Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan & Sadock’s synopsis of psychiatry (11th ed.). Wolters Kluwer. Chapter 8, Mood Disorders, Chapter 31, Child Psychiatry (Section 31.12 only)

Week 7 Comprehensive Psychiatrist evaluation and Patient Case Presentation

Schizophrenia , Psychosis Disorder

Babatunde Alli

Instructors: Dr. Agatha Parks-Savage

NRNP 6635 Psychopathology & Diagnosis Reasoniung Praticum

January 30 , 2022

Comprehensive Psychiatric Evaluation

CC (chief complaint): “I got caught into it.”

HPI: H.P. is a 40 y/o African American female who was transferred to ED via police due to bizarre and erratic behavior with auditory hallucinations ( responding to internal stimulus as evidenced by talking to people that we can not see visisbly). The patient attempted to stick people with a pen at a convenience store and shouting that they needed to be baptized. H.P is noted with hyper grandiosity and feels he is a mesire to help people by sacrificing their blood. The patient has had numerous hospitalizations in different hospitals but her last admission to this hospital was 3 years ago. The patient didn't follow up and was non-compliance with her medications. During the interview, the patient noted laughing and smiling inappropriately. Thoughts are racing and scattered. The patient was disorganized, delusional, paranoid, and suspicious of others. Feels watched and followed. Lacks energy and motivation. The patient has not been sleeping well at night. She reported she has been hearing voices telling her to kill herself. Denied visual hallucination and suicidal/homicidal ideations but observed responding to internal stimuli.

Past Psychiatric History:

· General Statement: The patient attempted to stick people with a pen at a convenience store. The patient has had numerous hospitalizations in different hospitals but her last admission to this hospital was 3 years ago. The patient didn't follow up and was non-compliance with her medications

· Caregivers (if applicable): The patient is not married, but she has 5 children, all are grown up and they all live with the other family members.

· Hospitalizations: Multiple hospitalizations, non-compliance to treatment.

· Medication trials: The patient didn't follow up and non-compliance with her medications

· Psychotherapy or Previous Psychiatric Diagnosis: Severe anemia, the cause not clear

Substance Current Use and History: The patient uses marijuana. Denied alcohol or other illicit drug-using.

Family Psychiatric/Substance Use History: The patient has a family history of bipolar and depression, but no detail was given. Due to patient being a poor historian and jumping from topic to topic upon interview.

Psychosocial History: The patient is not married, but she has 5 children, all are grown up and they all live with the other family members. The patient has no job. She receives a monthly social security check. The patient is currently homeless.

Medical History: Severe anemia, the cause not clear.

· Current Medications: chlorpromazine, 75 miligram per day until patient is controlled

· Allergies: No drug/food allergies were reported.

· Reproductive Hx: The patient is not married, but she has 5 children

ROS:

· GENERAL: There is no weight loss

· HEENT: No blurred vision

· SKIN: No itching and rashes

· CARDIOVASCULAR: No chest discomfort and chest pain

· RESPIRATORY: No coughing and shortness of breath

· GASTROINTESTINAL: No diarrhea and vomiting

· GENITOURINARY: No urgency in urination and odor

· NEUROLOGICAL: No numbness dizziness and headache

· MUSCULOSKELETAL: No stiffness, joint pain, and backbone

· HEMATOLOGIC: No bruising or bleeding

· LYMPHATICS: nodes are not enlarged

· ENDOCRINOLOGIC: sweating, cold, or heat was not reported

Physical exam: if applicable

Diagnostic results: Not applicable

Assessment

Mental Status Examination: H.P. is a 40 y/o African American female who was transferred to ED via police due to bizarre and erratic behavior with auditory hallucinations. The patient attempted to stick people with a pen at a convenience store. During the interview, the patient noted laughing and smiling inappropriately. Thoughts are racing and scattered. The patient was disorganized, delusional, paranoid, and suspicious of others. Feels watched and followed. Lacks energy and motivation. The patient has not been sleeping well at night. She reported she has been hearing voices telling her to kill herself. Denied visual hallucination and suicidal/homicidal ideations.

Diagnoses:

1. Schizophrenia, unspecified

A psychiatric illness marked by abnormalities in perception, thought, social relationships, and emotional reactivity. Even though the nature of schizophrenia differs from person to person, it is usually chronic and can be serious and devastating (Birch et.al, 2021). Delusions, hallucinations, and fundamentally aberrant cognition and behavior are all symptoms of schizophrenia, and they can make it very hard to operate regularly. Patients with schizophrenia must be medicated for the remainder of their lives. Early treatment can aid in improving the patient the lengthy outlook by surpassing high impact. Schizophrenia is featured by problems in thinking (cognition), feeling (emotions), and acting (behavior). Hallucinations, confused speech, and delusions, are major symptoms, and they show a reduced ability to perform. H.P has signs of schizophrenia as he is reported to be transferred to ED via police due to bizarre and erratic behavior with auditory hallucinations. The patient was disorganized, delusional, paranoid, and suspicious of others.

2. Marijuana use disorder

Cannabis addiction is usually related to dependency, which happens when an individual feels symptoms of withdrawal after discontinuing the use of the drug. Marijuana users commonly experience restlessness, low sleep issues, reduced appetite, desires, anxiety, and/or different forms of physical discomfort. These symptoms usually peak one week after stopping and can linger for up to two weeks. Cannabis is typically eaten in greater amounts or even for long durations than expected (Kalin, 2022). There appears to be a persistent desire, as well as futile measures, to decrease or restrict cannabis use. A significant amount of time is spent on chores that are needed to access cannabis, use cannabis, or recover from the drug's effects. Craving for cannabis or a burning urge to use it. Cannabis usage regularly causes failure to meet role commitments at the job, schooling, or family (Compton et.al, 2019). Persistent cannabis consumption despite having ongoing or recurring interpersonal and social issues caused or aggravated by cannabis' effects. The patient has marijuana use disorder as she is reported to be positive for marijuana.

3. Non-compliance with medications

Neglect or unwillingness to comply is referred to as noncompliance. In psychiatry, noncompliance refers to a client who fails to take a given medication or follow a recommended treatment plan. Causes of noncompliance with medication are; forgetfulness, misunderstanding, fear and worry, and suffering mental health. If a client has a mental disease that affects their state of mind, this can make it difficult for them to take their prescription on time and as recommended. Mental health assistance is critical throughout a patient's journey to enable them to feel their best and actively participate in their very own treatment (Pandey et.al, 2021). The client is reported that she didn’t follow up and non-compliance with her medications. Thus diagnosed with non-compliance with medication.

Reflections:

All health issues, whether physical or emotional, must be addressed. When a mental illness goes untreated, it can have disastrous consequences in many areas of one's life. While attending clinical training, one developed an awareness of mental health and how it affects an individual's day-to-day existence. H.P is a marijuana addict. The patient has not been sleeping well at night. She reported she has been hearing voices telling her to kill herself. Denied visual hallucination and suicidal/homicidal ideations. The patient presents as a danger to themself and others. This terrible scenario has the potential to harm others. One of the best things one can do for a patient suffering from mental health concerns is to encourage them to get therapy. If I were to assess the very same client as the therapist, I think I would use the same procedure. Furthermore, I would try to advise the client to do away with Marijuana as it has a huge side effect on his mental status.

References

Birch, K., Ling, A., & Phoenix, B. (2021). Psychiatric nurse practitioners as leaders in

Behavioral Health Integration. The Journal for Nurse Practitioners, 17(1), 112–115.

Week (#5): Case Presentation: Bipolar Disorder

Babatunde T Alli

College of Nursing-PMHNP, Walden University

NRNP 6635: Psychopathology and Diagnostic Reasoning

Faculty Name

Jan 21,2022

CASE STUDY

Name: Monica Dennis

Gender: Female

Age: 35-years-old

Height is 175, Weight is 69kg, BMI IS 22.5. Vital Signs: BP-129/73, T-98.1, R-20, P-86. Denies pain upon assessment

Background: Monica Dennis was born in New York City but later moved to ST. Louis, MO with her mother upon the death of her father who allegedly commit suicide by hanging.

HX: Monica is a 35-year-old AA with history of mental illness and multiple psychiatric hospitalization. She was referred to Touchette Regional hospital for voluntary admission by her psychiatrist. Client stated that “ I am ready to go and see my dad , I want to call it the end” She is also exhibiting symptoms such as audio and visual hallucinations, severe depression, feeling of hopelessness, worthlessness, agitation, anger outburst, isolating, and insomnia. Disorder that causes significant distress and interferes with normal daily routine. Exhibit mood swings and irrational behavior that is detrimental to her physical and mental wellbeing. Also, she has suicidal ideation with plan to take multiple pills out of her prescriptions.

Subjective:

CC (chief complaint): Client stated that “ I am ready to go and see my dad , I want to call it the end”.

HPI: Monica is a 35-year-old AA with history of mental illness and multiple psychiatric hospitalization. She was referred to Touchette Regional hospital for voluntary admission by her psychiatrist for suicidal ideation with plan. Patient did not currently have any gun and did not have access to gun. Patient denied ever wanting to destroy property or wanting to hurt other people. Client stated that “I am ready to go and see my dad, I want to call it the end” She is also exhibiting symptoms such as audio and visual hallucinations, severe depression, feeling of hopelessness, worthlessness, agitation, anger outburst, isolating, and insomnia. Disorder that causes significant distress and interferes with normal daily routine. Exhibit mood swings and irrational behavior that is detrimental to her physical and mental wellbeing. Also, she has suicidal ideation with plan to take multiple pills out of her prescriptions.

Past Psychiatric History: Patient was diagnosed and admitted for Major Depression with Suicide ideation at St. Mary hospital behavioral health, patient also report being admitted to Collinsville memorial hospital 7 months ago for psychosis.

· General Statement: Patient was first diagnosed with severe depression when she failed classes in her high school and wanted to kill herself. Patient was on medications but will take leave to different states with boyfriend where she will miss taking her meds and ends up being hospitalized.

· Caregivers (if applicable): Patient mother has played and still playing a significant role in making sure patient is safe and able to take care on self.

· Hospitalizations: This is the seventh psychiatric hospitalization, adherent is a major factor in patient’s case.

· Medication trials: Lithium, Depakote and Zoloft

· Psychotherapy or Previous Psychiatric Diagnosis: Major Depressive Disorder.

Substance Current Use and History: Patient has no history of substance abuse but smokes half a pack of cigarette daily. UDS positive for cocaine, opiate, meth amphetamines but positive for copd.

Family Psychiatric/Substance Use History: Monica’s mother has two other male children aged 21 who smokes cannabis relentlessly and was terminated before completing high school. Monica’s brother who is 27-year-old was a college dropout who drives trucks and a known alcoholic who has relapsed many times until his drivers’ licenses was revoked, many DUI’S. Patient has been hospitalized multiple times due to depression and sometimes alternate with manic episodes. Monica has always been non-compliance and always go back and forth to the hospital. Per previous medication history patient is on Lithium, Depakote and sertraline.

Psychosocial History: Patient report being single, children stays with her mother, she lost her job several years ago and no one would re-employ her because she’s on certain medications.

Medical History: Patient denied having any critical medical condition, CBC, CMP lipid panel, TSH level and Creatinine Clearance were all normal

· Current Medications: Lithium, Depakote, and Zoloft.

· Allergies: No known food or drug allergies

· Reproductive Hx: Patient has three daughters 9, 7, and 5

ROS:

· GENERAL: Height is 175, Weight is 69kg, BMI IS 22.5. Vital Signs: BP-129/73, T-98.1, R-20, P-86. Denies pain upon assessment

· HEENT: Head is symmetric, Normocephalic , pupil are rounds equal , reactive to light and accommodation. Ear, Nose and Throat: all clear. Neck is supple, no jugular vein distention. No thyroidmegally

· SKIN: Normal skin Turgor

· CARDIOVASCULAR: Regular heartbeat, no murmur or gallop heard upon auscultations. S1, S2 regular.

· RESPIRATORY: Lungs are clear upon auscultations, chest normal regular breathing, no labor breathing observed.

· GASTROINTESTINAL: Abdomen soft and non-tender. No organomegaly, Bowel sounds presents at four quadrants, surgical scare at the lower middle quadrant

· GENITOURINARY: Patient able to urinate without difficulty, no burning or painful urination

· NEUROLOGICAL: Cognitively impaired

· MUSCULOSKELETAL: physically normal

· HEMATOLOGIC: All blood labs normal

· LYMPHATICS: no abnormality mentioned

· ENDOCRINOLOGIC: No abnormality observe.

Objective:

Physical exam: Patient walks into the interview without any assistance, patient is physically energetic. Height is 175, Weight is 69kg, BMI IS 22.5. Vital Signs: BP-129/73, T-98.1, R-20, P-86. Denies pain upon assessment

Diagnostic results: Upon review of the data presented to me at the clinic as at time of evaluation and assessment; WBC 9.8, HGB 14.9, HMTC 34.5, PLATELETS 379, BUN 9, Creatinine 0.6.Glucose 121, Calcium 10.5, LDL 46. HDL 38. Patient is Covid-19 negative with PCR antigen test.

Assessment: Upon assessment patient is alert and oriented to person, place, time and situation, guarded and snobby at the beginning of the interview.

Mental Status Examination: Appearance normal (Patient is appropriate for stated age) Eye Contact: Minimum eye contact noted, Hygiene: Patient is somehow untidy, needs improvement with Hygiene. Psychomotor Activity: No tremor, no agitations observed. Attention and Concentration: Patient is attentive with minimal concentration observed. Speech: Patient speaks at a fast pace, with mildly loud volume, pressured at most times upon asking questions. Thought process is disorganize with tangential hallucinations, thought content: Patient reports command and auditory and observed with responses tom internal stimuli. Mood: Patient is guarded, anxious , hallucinating and labile. Affect: flat. Patient is still endorsing suicidal ideation with plan, denies delusion, denies homicidal ideations. Patient insight is poor, and she is non-compliance with medication.

Major Diagnosis

Bipolar Disorder

Differential Diagnoses:

Anxiety

Mania

Major depressive disorder

Medication non-compliant

Tobacco (Nicotine) addiction Disorder

Reflections:

Saddock et al.,(2015) Claims that mood disorder (Major depressive disorder) is the most common type of psychiatric illness with prevalence of 5-17%. Bipolar disorder on the other hand has the milder prevalence of less t