Case Study: Complex Psychiatric/Medical Adult/Geriatric Patient
Complete a Psychiatric Initial Assessment on the patient based on the Case Study information. Then complete a plan of care. Lastly, include answers to the questions listed at the bottom of your completed psychiatric initial assessment template.
Case Study: Complex Psychiatric/Medical Adult/Geriatric Patient
Use the template to complete a Psychiatric Initial Assessment on the patient based on the Case Study information. Then complete a plan of care. Lastly, include answers to the questions listed at the bottom of your completed psychiatric initial assessment template.
Case Presentation
Darron is a 68-year-old white widower and retired accountant. He was referred for psychosocial evaluation at the diabetes clinic after an emergency room (ER) visit to a local hospital. He arrived at the ER with confusion and a severe hypoglycemic episode after taking an overdose of insulin. He denied suicidal intent or alcohol abuse and claimed to have mistakenly taken insulin lispro rather than his insulin glargine dose. The ER staff was suspicious about his claim because there had been eight similar ER visits for severe hypoglycemia within the last two years. He explained these previous events as a result of mixing up the types of insulin he injected.
After psychiatric assessment he was not judged to be a suicidal risk. He was discharged after his blood glucose levels stabilized, and he promised to pursue outpatient mental health treatment. His hemoglobin A1c (A1C) at the time was 7.9% – his lowest on record for several years. Generally, his blood glucose levels displayed wide swings. He explained that high blood glucose levels made him feel more apathetic about eating and depressed about his diabetes self-management.
Personal history
As a child, Darron attained developmental milestones at expected times. His father was in the Army, and as a result, Darron had moved 32 times before he graduated from high school. He was an excellent student throughout high school but only managed mediocre grades in college because of family conflict. He dropped out of college in his junior year and moved to a South Pacific island for one year.
After returning to the United States, he earned an undergraduate degree in English and then a second degree in accounting. After graduation, he married and worked for 20 years as an accountant in a group practice. Later, Darron started his own accounting firm, but he had difficulty keeping organized and recalls being constantly late for business meetings and failing to complete projects on time. In hindsight, Darron believes that he has struggled with depression on and off for > 30 years. He first recalls feeling depressed after his diagnosis with diabetes 36 years ago. He felt more depressed after he lost his 47-year-old sister to colon cancer in 1988, and then his 74-year-old father died from heart disease in 1991. But, he says his life “really fell apart” when his 54-year-old wife died from lung cancer in 1995. He contemplated suicide for three months but never acted. During this desperate period, he marginally functioned, lost many business clients, and was forced to close his company.
Overwhelmed by depression, he moved to the West Coast to live with his mother and worked at unskilled jobs. Diabetes complicated his emotional struggles, with blood glucose control fluctuating wildly and ranging from episodes of ketoacidosis that required hospitalization to severe hypoglycemic events that resulted in car crashes. Depression complicated his diabetes management, and after a hypoglycemia-related auto accident in which he ran over several pedestrians, he decided to stop working and was approved for social security because of psychiatric disability.
He came to the East Coast in 1998 to briefly visit his younger brother and decided to stay. Although he still lives near his brother, he says they have had only sporadic contact since a falling out after Darron “passed out” during a severe hypoglycemic episode. In 2010, Darron got engaged, but his fiancée left him to marry the father of her child. He says he felt devastated by the loss of yet another woman who had “become everything” to him. Since then, he has withdrawn socially and does not leave his apartment unless it is necessary. He has trouble managing his money, keeping his apartment neat and orderly, taking medications on time, and maintaining any structure in his day.
Medical history
Darron punctually arrives at the correct hour but often on the wrong day for his medical appointments. He grapples with neuropathy, retinopathy, and unpredictable blood glucose levels. He monitors his blood glucose levels 8–12 times/day and tries to be careful about what he eats. He also has sleep apnea, and his sleep patterns are highly erratic. He frequently does not fall asleep until 4:00 a.m. and then may only be able to sleep for 2 hours. Often, he will then nap for several hours in the afternoon. He began continuous positive airway pressure treatment for his sleep problems in 2003 but did not tolerate treatment. He has switched to bilevel positive airway pressure (biPAP) within the last 18 months but only tolerates it for up to 3 hours each night. Additional diagnoses include hyperlipidemia, hypertension, atrial fibrillation, Meniere's disease, tinnitus, and arthritis. His medication list includes atorvastatin, lisinopril, hydrochlorothiazide, warfarin, meclizine, and folic acid. He does not smoke and only rarely drinks alcohol. Only his paternal grandmother had diabetes.
Psychiatric history
Depression has plagued Darron since his diagnosis with diabetes. As noted earlier, his depression intensified after the deaths of his sister and father, but he did not descend into a suicidal mood until his wife died 10 years ago. Four years ago, he underwent electroconvulsive therapy (ECT), and although he continues to have occasional suicidal ideation, he has not made an attempt and has had no further psychiatric admissions. Both of his parents, his brother, and his sister suffered from depression. A maternal aunt suffered from dementia. His mother also struggled with alcohol abuse until her death from emphysema in 2004 at the age of 89. At the time of referral, he was taking fluoxetine, 40 mg, and venlafaxine, 37.5 mg, prescribed by a PMHNP.
Questions
1. Was Darron's insulin overdose accidental or a suicide attempt based on clinical decision making you would invoke as a PMHNP?
2. What are the causes for his cognitive impairment?
3. How does his depression and cognitive problems affect his diabetes self-management?
Initial Psychiatric SOAP Note Template
There are different ways in which to complete a Psychiatric SOAP (Subjective, Objective, Assessment, and Plan) Note. This is a template that is meant to guide you as you continue to develop your style of SOAP in the psychiatric practice setting.
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Criteria |
Clinical Notes |
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Informed Consent |
Informed consent given to patient about psychiatric interview process and psychiatric/psychotherapy treatment. Verbal and Written consent obtained. Patient has the ability/capacity to respond and appears to understand the risk, benefits, and (Will review additional consent during treatment plan discussion) |
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Subjective |
Verify Patient Name: DOB: Minor: Accompanied by: Demographic: Gender Identifier Note: CC: HPI: Pertinent history in record and from patient: X During assessment: Patient describes their mood as X and indicated it has gotten worse in TIME. Patient self-esteem appears fair, no reported feelings of excessive guilt, no reported anhedonia, does not report sleep disturbance, does not report change in appetite, does not report libido disturbances, does not report change in energy, no reported changes in concentration or memory. Patient does not report increased activity, agitation, risk-taking behaviors, pressured speech, or euphoria. Patient does not report excessive fears, worries or panic attacks. Patient does not report hallucinations, delusions, obsessions or compulsions. Patient’s activity level, attention and concentration were observed to be within normal limits. Patient does not report symptoms of eating disorder. There is no recent weight loss or gain. Patient does not report symptoms of a characterological nature. SI/ HI/ AV: Patient currently denies suicidal ideation, denies SIBx, denies homicidal ideation, denies violent behavior, denies inappropriate/illegal behaviors. Allergies: NKDFA. (medication & food) Past Medical Hx: Medical history: Denies cardiac, respiratory, endocrine and neurological issues, including history head injury. Patient denies history of chronic infection, including MRSA, TB, HIV and Hep C. Surgical history no surgical history reported If Minor obtain Developmental Hx: (most often from parents), in utero, birth and delivery hx, early childhood, school hx, behavior, etc… Nutritional status (this is an important component to gauge how well the mind and body are being nourished for full function. Ex: lack of iodine create thyroid issues, thyroid issues creates metabolism issues which affects function of cognition, mood, etc…) Past Psychiatric Hx: Previous psychiatric diagnoses: none reported. Describes stable course of illness. Previous medication trials: none reported. Safety concerns: History of Violence to Self: none reported History of Violence t o Others: none reported Auditory Hallucinations: Visual Hallucinations: Mental health treatment history discussed: History of outpatient treatment: not reported Previous psychiatric hospitalizations: not reported Prior substance abuse treatment: not reported Trauma history: Client does not report history of trauma including abuse, domestic violence, witnessing disturbing events. Substance Use: Client denies use or dependence on nicotine/tobacco products. Client does not report abuse of or dependence on ETOH, and other illicit drugs. Current Medications: No current medications. (Contraceptives): Supplements: Past Psych Med Trials: Family Medical Hx: Family Psychiatric Hx: Substance use Suicides Psychiatric diagnoses/hospitalization Developmental diagnoses Social History: Occupational History: currently unemployed. Denies previous occupational hx Military service History: Denies previous military hx. Education history: completed HS and vocational certificate Developmental History: no significant details reported. (Childhood History) Legal History: no reported/known legal issues, no reported/known conservator or guardian. Spiritual/Cultural Considerations: none reported. ROS: Constitutional: No report of fever or weight loss. Eyes: No report of acute vision changes or eye pain. ENT: No report of hearing changes or difficulty swallowing. Cardiac: No report of chest pain, edema or orthopnea. Respiratory: Denies dyspnea, cough or wheeze. GI: No report of abdominal pain. GU: No report of dysuria or hematuria. Musculoskeletal: No report of joint pain or swelling. Skin: No report of rash, lesion, abrasions. Neurologic: No report of seizures, blackout, numbness or focal weakness. Endocrine: No report of polyuria or polydipsia. Hematologic: No report of blood clots or easy bleeding. Allergy: No report of hives or allergic reaction. Reproductive: No report of significant issues. (females: GYN hx; abortions, miscarriages, pregnancies, hysterectomy, PCOS, etc…) |
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Verify Patient: Name, Assigned identification number (e.g., medical record number), Date of birth, Phone number, Social security number, Address, Photo. Include demographics, chief complaint, subjective information from the patient, names and relations of others present in the interview. HPI: , Past Medical and Psychiatric History, Current Medications, Previous Psych Med trials, Allergies. Social History, Family History. Review of Systems (ROS) – if ROS is negative, “ROS noncontributory,” or “ROS negative with the exception of…” |
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Objective |
Temp: BP: HR: R: O2: Pain: Ht: Wt: BMI: BMI Range: LABS: Lab findings WNL Tox screen: Negative Alcohol: Negative HCG: N/A Physical Exam: MSE: Patient is cooperative and conversant, appears without acute distress, and fully oriented x 4. Patient is dressed appropriately for age and season. Psychomotor activity appears within normal. Presents with appropriate eye contact, euthymic affect – full, even, congruent with reported mood of “x”. Speech: spontaneous, normal rate, appropriate volume/tone with no problems expressing self. TC: no abnormal content elicited, denies suicidal ideation and denies homicidal ideation. Process appears linear, coherent, goal-directed. Cognition appears grossly intact with appropriate attention span & concentration and average fund of knowledge. Judgment appears fair . Insight appears fair The patient is able to articulate needs, is motivated for compliance and adherence to medication regimen. Patient is willing and able to participate with treatment, disposition, and discharge planning. Diagnostic testing: · PHQ-9, psychiatric assessment |
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This is where the “facts” are located. Vitals, **Physical Exam (if performed, will not be performed every visit in every setting) Include relevant labs, test results, and Include MSE, risk assessment here, and psychiatric screening measure results. |
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Assessment |
DSM5 Diagnosis: with ICD-10 codes Dx: – Dx: – Dx: – Patient has the ability/capacity appears to respond to psychiatric medications/psychotherapy and appears to understand the need for medications/psychotherapy and is willing to maintain adherent. Reviewed potential risks & benefits, Black Box warnings, and alternatives including declining treatment. |
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Include your findings, diagnosis and differentials (DSM-5 and any other medical diagnosis) along with ICD-10 codes, treatment options, and patient input regarding treatment options (if possible), including obstacles to treatment. Informed Consent Ability |
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Plan |
Inpatient: Psychiatric. Admits to X as per HPI. Estimated stay 3-5 days Patient is found to be stable and has control of behavior. Patient likely poses a minimal risk to self and a minimal risk to others at this time. Patient denies abnormal perceptions and does not appear to be responding to internal stimuli. Pharmacologic interventions: including dosage, route, and frequency and non-pharmacologic: · No changes to current medication, as listed in chart, at this time · or…Zoloft is an excellent option for many women who experience any menstrual cycle complaints. I usually start at 50 mg and move to 100 week 6-8. f/u within 2 weeks initially then every 6-8 weeks. · Psychotherapy referral for CBT Education, including health promotion, maintenance, and psychosocial needs · Importance of medication · Discussed current tobacco use. NRT not indicated. · Safety planning · Discuss worsening sx and when to contact office or report to ED Referrals: endocrinologist for diabetes Follow-up, including return to clinic (RTC) with time frame and reason and any labs that are needed for next visit 2 weeks ☒ > 50% time spent counseling/coordination of care. Time spent in Psychotherapy 18 minutes Visit lasted 55 minutes Billing Codes for visit: XX XX XX ____________________________________________ NAME, TITLE Date: Click here to enter a date. Time: X |
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Include a specific plan, including medications & dosing & titration considerations, lab work ordered, referrals to psychiatric and medical providers, therapy recommendations, holistic options and complimentary therapies, and rationale for your decisions. Include when you will want to see the patient next. This comprehensive plan should relate directly to your Assessment and include patient education. |
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