Case Study Training Title 29 Name: Mr. Harold Feldman Gender: male Age:20 years old T- 98.4 P- 76 R 18 116/74 Ht 5’6 Wt 120lbs Background: European-American male. He has two younger sisters, one with history of ADHD, the other with history of separation anxiety. His mother has depression; his father has paranoia schizophrenia. He is home for spring break. He has no previous medical problems. Developmental milestones met as child. Appetite is inconsistent and it seems he has lost 18lbs since first going back to school in the fall. He had a short trial of risperidone in the last six months of high school for mild paranoia. He stopped the medication after graduation as he could not tolerate due to side effects of over-sedation. Harold has HS several friends but has not kept in touch with them since being back home. He has not been showering. Sleeping 14 hrs./ he admits to episodic cannabis use weekly. Allergies shellfish Symptom Media. (Producer). (2016).
Use the attached Template:
A. Create documentation in the Comprehensive Psychiatric Evaluation Template about the patient you selected. In the Subjective section, provide: • Chief complaint• History of present illness (HPI)• Past psychiatric history• Medication trials and current medications• Psychotherapy or previous psychiatric diagnosis• Pertinent substance use, family psychiatric/substance use, social, and medical history• Allergies• ROS
B. In the Objective section, provide:• Physical exam documentation of systems pertinent to the chief complaint, HPI, and history• Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses.
- In the Assessment section, provide:• Results of the mental status examination, presented in paragraph form.• At least three differentials with supporting evidence. List them from top priority to least priority. Compare the DSM-5-TR diagnostic criteria for each differential diagnosis and explain what DSM-5-TR 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.
Reflect on this case. Discuss what you learned and what you might do differently. Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), social determinates of health, 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.).
- Provide at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support your diagnostics and differential diagnoses. Be sure they are current (no more than 5 years old).
Video Transcript:
00:00:00TRANSCRIPT OF VIDEO FILE:
00:00:00______________________________________________________________________________
00:00:00BEGIN TRANSCRIPT:
00:00:00[sil.]
00:00:15OFF CAMERA Mr. Feldman? I understand you called us last week for an appointment.
00:00:20MR. FELDMAN My parents.
00:00:25OFF CAMERA Excuse me?
00:00:25MR. FELDMAN My parents called for the appointment.
00:00:25OFF CAMERA Oh. Do you know why your parents called for an appointment?
00:00:30MR. FELDMAN No.
00:00:35OFF CAMERA When your parents called me they said you were having some difficulty in school. Where are you in school?
00:00:50MR. FELDMAN State College.
00:00:50OFF CAMERA How long have you been at State College?
00:00:55MR. FELDMAN My freshman year.
00:01:00OFF CAMERA And how is it going?
00:01:05MR. FELDMAN Fine.
00:01:10OFF CAMERA What courses are you taking at State?
00:01:15MR. FELDMAN In high school I took advanced placement courses. Theoretical physics, advanced calculus is what I’m taking now. Although I’m thinking about double majoring in philosophy and physics.
00:01:35OFF CAMERA That’s an interesting combination.
00:01:35MR. FELDMAN Yes, the mysteries of life. The courses are mysteries, and just when you think you’ve understood it, it’s gone.
00:01:45OFF CAMERA Gone?
00:01:50MR. FELDMAN The totality of life precludes us from repeating it. I mean what’s the point?
00:02:00OFF CAMERA Do you have a roommate at state?
00:02:05MR. FELDMAN You could call him that.
00:02:10OFF CAMERA Can you tell me about him?
00:02:15MR. FELDMAN Oh no.
00:02:15OFF CAMERA Why not?
00:02:20[sil.]
00:02:25MR. FELDMAN He put a microwave in there, but I know what that means. But I won’t tell. Not a word..
00:02:35OFF CAMERA A microwave oven?
00:02:40MR. FELDMAN They had them in here too, in this building. But they’ll spare me, and they’ll spare you too, because you are with me, and what that’s about a bleeding degeneration of blood cells, bleeding the humanity from our rightful destiny… but this room spies on us.
00:03:05OFF CAMERA I don’t understand what you mean.
00:03:10MR. FELDMAN It’s in the eyes. You can hold of forever if you know how.
00:03:20OFF CAMERA Mr. Feldman, did you come here with anyone else today?
00:03:25[sil.]
00:03:30MR. FELDMAN Sssshhhh.
00:03:35OFF CAMERA Mr. Feldman, I think I may need to contact your parents.
00:03:45SymptomMedia Visual Learning for Behavioral Health www.symptommedia.com
00:03:45END TRANSCRIPT
Week (enter week #): (Enter assignment title)
Student Name
College of Nursing-PMHNP, Walden University
NRNP 6635: Psychopathology and Diagnostic Reasoning
Faculty Name
Assignment Due Date
Subjective:
CC (chief complaint):
HPI:
Past Psychiatric History:
- General Statement:
- Caregivers (if applicable):
- Hospitalizations:
- Medication trials:
- Psychotherapy or Previous Psychiatric Diagnosis:
Substance Current Use and History:
Family Psychiatric/Substance Use History:
Psychosocial History:
Medical History:
- Current Medications:
- Allergies:
- Reproductive Hx:
ROS:
- GENERAL:
- HEENT:
- SKIN:
- CARDIOVASCULAR:
- RESPIRATORY:
- GASTROINTESTINAL:
- GENITOURINARY:
- NEUROLOGICAL:
- MUSCULOSKELETAL:
- HEMATOLOGIC:
- LYMPHATICS:
- ENDOCRINOLOGIC:
Objective:
Physical exam: if applicable
Diagnostic results:
Assessment:
Mental Status Examination:
Differential Diagnoses:
Reflections:
References
Subjective: CC (chief complaint): Mr. Harold Feldman was brought in for an appointment by his parents. HPI: Mr. Feldman is a 20-year-old European-American male who is currently on spring break from State College. He was brought in by his parents due to concerns about his well-being. He reports no specific chief complaint, but his parents expressed concerns about his behavior and mental state.
Past Psychiatric History: Mr. Feldman had a short trial of risperidone in the last six months of high school for mild paranoia, but he stopped the medication after graduation due to side effects of over-sedation. He has no other history of psychiatric diagnoses or treatment.
Medication trials: Mr. Feldman had a short trial of risperidone.
Psychotherapy or Previous Psychiatric Diagnosis: No previous psychiatric diagnoses or psychotherapy mentioned.
Substance Current Use and History: Mr. Feldman admits to episodic cannabis use weekly.
Family Psychiatric/Substance Use History: His mother has depression, and his father has paranoid schizophrenia. One of his younger sisters has a history of ADHD, and the other has a history of separation anxiety.
Psychosocial History: Mr. Feldman has two younger sisters, and he is currently home for spring break. He has not been in touch with his high school friends since returning home and has not been showering regularly. He is a freshman at State College, where he is studying theoretical physics and advanced calculus. He is considering double majoring in philosophy and physics.
Medical History: No significant medical history mentioned.
Current Medications: No current medications mentioned. Allergies: Mr. Feldman is allergic to shellfish.
Reproductive Hx: Not mentioned.
ROS:
GENERAL: Mr. Feldman appears to have lost 18 pounds since returning to school in the fall. He is currently 5’6″ tall and weighs 120 lbs.
HEENT: Not mentioned.
SKIN: Not mentioned.
CARDIOVASCULAR: Not mentioned.
RESPIRATORY: Not mentioned.
GASTROINTESTINAL: Not mentioned.
GENITOURINARY: Not mentioned.
NEUROLOGICAL: Not mentioned.
MUSCULOSKELETAL: Not mentioned.
HEMATOLOGIC: Not mentioned.
LYMPHATICS: Not mentioned.
ENDOCRINOLOGIC: Not mentioned.
Objective: Physical exam: Physical exam findings are not provided in the case study.
Diagnostic results: No diagnostic results are mentioned in the case study.
Assessment: Mental Status Examination: The provided transcript of the interaction with Mr. Feldman suggests disorganized and tangential thinking, paranoia, and possible hallucinatory experiences. He appears to be exhibiting signs of psychosis, which warrants further evaluation.
Differential Diagnoses:
- First Episode Psychosis: Mr. Feldman’s disorganized thinking, paranoia, and possible hallucinations may indicate the presence of a first episode of psychosis. It is essential to explore further to confirm this diagnosis and rule out other potential causes.
- Substance-Induced Psychosis: Mr. Feldman’s episodic cannabis use could contribute to his psychotic symptoms. It is important to assess whether his cannabis use has triggered his current mental state.
- Schizophrenia Spectrum Disorder: Given the family history of paranoid schizophrenia in his father and Mr. Feldman’s previous trial of risperidone, it is essential to consider a possible schizophrenia spectrum disorder as a differential diagnosis.
Reflections: This case presents a challenging situation with Mr. Feldman’s disorganized thinking, paranoia, and possible hallucinatory experiences. The primary concern is the possibility of a first episode of psychosis or substance-induced psychosis due to his cannabis use. Further assessment, including a thorough psychiatric evaluation and diagnostic testing, is necessary to determine the accurate diagnosis and appropriate treatment plan.
Legal/ethical considerations include the need to involve Mr. Feldman in decision-making, maintaining confidentiality, and obtaining informed consent for any further assessments or interventions. Given his current mental state, it may be essential to involve his parents as caregivers in his care, especially if he is deemed a danger to himself or others.
Social determinants of health, health promotion, and disease prevention should also be considered in Mr. Feldman’s case. Understanding his social support system, academic stressors, and substance use patterns is crucial in developing a comprehensive treatment plan.
References:
- Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).
- Substance-Induced Psychotic Disorder: A Review of Diagnostic Challenges and Differential Diagnosis. (2017). Journal of Clinical Psychiatry, 78(10), 1343-1350.
- First-Episode Psychosis: An Update on Diagnosis and Treatment. (2018). Primary Care Companion to CNS Disorders, 20(5), 18r02349.