NKU MSN675 Complete Course Latest 2022 February (Full)

MSN675 MANAGEMENT OF PSYCHIATRIC MENTAL HEALTH DISORDERS

Module 1 Discussion

Mood disorders

For the discussion boards this term  please include:

Any differential diagnoses

Your diagnosis and reasoning

Any additional questions you would have asked

 Medication recommendations along with your rationale. Note possible side effects or issues to address if attempting to obtain consent.

Any labs and why they may be indicated

Screener scales or diagnostic tools that may be beneficial

Additional resources to give  (Therapy modalities, support groups, activities, etc.)

Discuss and answer questions related to the case presentations on the discussion board.  You will need to utilize all of your nursing skills when evaluating the data.

Group with last names A-L

mod1 case study 1.doc

Group with last names M-Z

mod 1 case 2-2.docx

Instructions:

Make your initial post by 23:59 EST Wednesday of Week 1 .

Respond to two other classmates’ posts by 23:59 EST Sunday of Week 1.

Use APA format.

This is an excellent way to share learned knowledge and tips with peers and to hear others’ perspectives on things before you start practicing.

History of present illness:

Case Study 1

The 43-year-old woman walks into the medical emergency department naked and confused at 215 in the morning. On initial triage, vital signs are stable, but the patient appears to have an unsteady gait and tremor. The patient vomits shortly after being seen. She is oriented person only, unaware of her location, the date, or any of the events leading up to her presentation. She cannot provide her address or any identifying information, except to mumble” Depakote, lithium, Tegretol, lots,” when asked what medications she is taking. She is confused at several points during the interview but never lethargic, and her thought processes are disorganized. She repeatedly laughs inappropriately and does not appear concerned by the fact he has arrived without clothing. She remains calm in the ER but does not understand why is there or how she arrived. No prior charts are available to review the history, and the patient is unreliable due to confusion and unable to provide contact information.

It was a cold evening, with a temperature of approximately 40°F, and the patient is noted to be shivering. There are no other signs of hypothermia, and there is no evidence of bruising or physical trauma. Blood is drawn and a psychiatric consult is called.

Mental status examination:

The patient is well groomed despite being without clothes. She is wearing hospital pajamas and covering herself with a blanket around her shoulders. She sits calmly in a chair and is cooperative with the interview. Her speech is soft, mumbling, dysarthric, and almost incoherent at times. Her psycho motor behavior is affected by a tremor, but no other abnormal movements or is any agitation, observed. She appears euthymic and seems to understand questions related to her mood. Her affect is inappropriate at times; she smiles oddly with frequent laughing. Her thought processes are disorganized; she does not answer the questions directly and goes off on tangents or includes many irrelevant details in her responses. She appears internally preoccupied during the interview, frequently staring into space, although it is difficult to assess directly whether she is experiencing auditory hallucinations. There is no evidence of suicidality or homicidality based on observations in the emergency rooms. She is alert but oriented to person only; she is able to name the month but gives the wrong date and day of the week. She is able to name the city but does not know that she is in a hospital and cannot identify or locate.

Physical examination:

Temperature, 36.7°C; heart rate 55 beats/per minute; blood pressure 130/; respirations 18.

General: she is well-nourished, well appearing adult in no apparent distress.  HEENT: no evidence of head trauma. Pupils are equal and reactive to light, extra ocular movements are intact, and the oropharynx is clear. Oral mucous membranes are dry, and there are no signs of goiter or JVD. Cardiac: decreased rate to 55 bpm but regular rhythm with no murmurs, gallops, or rubs. Chest: clear to auscultation bilaterally. Abdomen: soft, nontender, not jdistended, with positive bowel sounds. Extremities: no signs of clubbing, cyanosis or edema.

Neurologic examination:

Mild ataxia, of course tremor, hypereflexia. Cranial nerves 2-12 are intact, but nystagmus is observed; strength is 4/5 upper and lower extremities; sensation is difficult to test; coordination is impaired.

Diagnostic testing:

CT of the brain: no signs of mass, bleeding or infarct. EKG: normal sinus rhythm at 58, with T wave flattening. E.EG: diffuse slowing, no seizure foci.

Laboratory examination:

CBC showed elevated white blood cells to 12.3, with no left shift. Chemistry showed mild dehydration; serum toxicology was negative. Liver, thyroid function tests, and UA were within normal limits. Carbamazepine and valproic acid levels were undetectable. The serum lithium level was 2.3mEq/L. Alcohol level was negative.

Questions:

What is the most probable cause of the patient’s confusion? Explain your answer.

•             Any differential diagnoses

•             Your diagnosis and reasoning

•             Any additional questions you would have asked

•             Medication recommendations along with your rationale. Note possible   side effects or issues to address if attempting to obtain consent.

•             Any labs and why they may be indicated

•             Screener scales or diagnostic tools that may be beneficial

•             Additional resources to give  (Therapy modalities, support groups, activities, etc.)

Case Study 2

A 74 year old gentleman presents to your office with a 20 year history of depression.  He is accompanied by his wife of 50 years.  His family is concerned because he has begun to exclude himself from routine family activities.  He is a retired police office but has remained part of the community despite his multiple medical complications.  Most specifically is a femoral popliteal graph with a “rubber” vein that has led to chronic venous insufficiency and more importantly chronic intractable pain.  Over the years he has tried all of the SSRI’s and is currently taking Wellbutrin XL 300mg and Gabapentin 900 mg tid. He also takes a BID dose of Oxycodone but is still unable to sleep for more than 2-3 hours at a time due to his pain. He has also tried Elavil in the past without relief.

What is your primary concern with this gentleman?

 

MSN675 MANAGEMENT OF PSYCHIATRIC MENTAL HEALTH DISORDERS

Module 2 Discussion

Anxiety

Online Discussion

Any differential diagnoses

Your diagnosis and reasoning

Any additional questions you would have asked

 Medication recommendations along with your rationale. Note possible side effects or issues  to address if attempting to obtain consent.

Any labs and why they may be indicated

Screener scales or diagnostic tools that may be beneficial

Additional resources to give  (Therapy modalities, support groups, activities, etc.)

 According to the DSM what is the difference between agoraphobia and social anxiety?  (This will be on boards).

Post Case Study

 Group 1: (Last names A-K)

Group 2: (Last names L-Z)

Case Study 1

26 y/o male

History of Present Illness:

A 26-year-old man is transferred from the medical emergency department to psychiatry after receiving sutures to multiple lacerations on both wrists. The patient was initially brought to the emergency department by a friend who found him in the bathtub, bleeding from his wrists. When the patient is asked to move into an exam room to be interviewed, the examiner notes that he 1st unties and reties his shoes 3 times. When the interviewer finally begins, the patient reports that in recent months he has become disturbed “by his life and the way things are going.” He describes feeling” ugly” and” worthless” and is” tired of dealing with everything”. When asked about his suicide attempt, he states,” the past few days have been really bad… It’s all coming apart now.” He then begins to cry uncontrollably.

When the patient regains composure, that he is a writer who has recently signed a deal to publish novel. He was scheduled to the photographed for the book jacket cover earlier today and feels” overwhelmed” by the idea of being photographed and having the photo publicly released. When asked why he felt overwhelmed, he points to the skin around his mouth, where multiple small lesions in various stages of healing are appreciated. The patient describes an ongoing concern about the thickness of his mustache, despite being clean shaven. He reports shaving 3to 4 times every day and then using tweezers between shaves to prevent more growth. He endorses feeling this way for the past year,” ever since I got my nose fixed.” The patient also admits to repeatedly checking for hair growth in the mirror and feeling that people in the street are constantly looking at his mustache. The patient notes that he lives alone, works from home, and has few friends. He rarely leaves the house because he does not want” to be around people”. He also appears anxious to end the interview and interrupts the examiner to ask if he can go to the bathroom. When asked why, he seems embarrassed but admits to wanting to check his skin and wash his hands.

Past Psychiatric history:

The patient denies any previous psychiatric treatment. He has never been hospitalized or taken psychiatric medication. He was once referred for depressive symptoms but never followed up.

Past medical history:

The patient admits to seeing a dermatologist for” skin problems” and has a history of 2 rhinoplasties in the past 5 years.

Mental status exam:

The patient is a good- looking man who appears his stated age.  He is disheveled in appearance but clean shaven.   He has limited eye contact, and his speech is slow and quiet.  The patient keeps his hand over his mouth throughout the interview and moves it only slightly to speak.  When his hand is moved, the lesions around his lips can be seen, and some appear infected.  He reports that his mood is “really bad”, and his affect is constricted to the dysphoric range.  He cries openly and at times uncontrollably.  His thought process is linear and goal directed.  He describes feeling that people on the street are looking at him and talking about his skin but denies other disturbance in thought content.  He denies homicidal ideation but still endorses suicidal ideation.  When asked about a plan, he replies, “well something better than cutting my wrists”.  He denies auditory and visual hallucinations.  He is alert and orients, with good attention and intact memory and concentration.  His insight and judgment appear poor.

Case Study 2

49 y/o male

HX of Present Illness: 

A 49 y/o male with a history of hypertension and obesity presents to the ER during the evening.  He complains of a bad headache, shortness of breath and mild chest pain and is found to have a B/P of 185/120 with apulse rate of 95 but normal respirations.  He received clonidine for hypertension, which resolves without incident.  The patient describes feeling worried and upset about his blood pressure, which is high again, even though he takes his medication and visits his primary regularly.  The provider in the ER suggests speaking to a psychiatric provider about his anxiety.

The Psych NP on call consults with the patient.  Over the past year, the patient reports worsening anxiety since being diagnosed with hypertension.  He has started exercising and dieting and has reduced his cigarette habit to only 1 cigarette a day.  Continued hypertension visits to his primary cause him to worry even more. He fears he will never again gain control of his health and that he may even die.  He experiences significant stress about salt and fat in his diet and feels that these thoughts constantly occupy his mind.  He also worries about other issues in his life aside from other health concerns, such as driving his car safely and completing details at work.  He states that he ruminates about these issues almost all of the time and sometimes has trouble sleeping at night as a result.  He reports never feeling rested during the day and at times describes aches and pains in his body.

     Lately he has felt even more tense and irritable at work, leading to some arguments with co-workers.  He states, that beginning 1 month ago, he began to experience moments of intense fear and panic wondering if he will die.  Generally he reports wishing to live his life to the fullest and strongly denies any suicidality.  He has a depressed mood at times, however, related to his medical problems and stress, and wonders if his health will ever improve.

Past Psychiatric Hx:

The patient has never received psychiatric care.  He states that he has been a somewhat “high-strung person” his entire life but has never felt this kind of anxiety until last year.  He denies heavy alcohol or illicit substance abuse.  No psychiatric hospitalizations or suicide attempts.  He denies any family history of psychiatric illness or substance abuse.  He lives with his wife and two preteen boys.

Physical Exam:

Unremarkable except for obesity.

Labs:

CBC and electrolytes are within normal limits, TSH is normal, and cardiac enzymes are not elevated.  UA and toxicology screen are negative.

Diagnostic Testing:

EKG shows non-specific S-T abnormalities and no acute changes.

 

MSN675 MANAGEMENT OF PSYCHIATRIC MENTAL HEALTH DISORDERS

Module 3 Discussion

Eating disorders and Personality disorders

For the discussion boards this term  please include:

Any differential diagnoses

Your diagnosis and reasoning

Any additional questions you would have asked

 Medication recommendations along with your rationale. Note possible side effects or issues  to address if attempting to obtain consent.

Any labs and why they may be indicated

Screener scales or diagnostic tools that may be beneficial

Additional resources to give  (Therapy modalities, support groups, activities, etc.)

 

MSN675 MANAGEMENT OF PSYCHIATRIC MENTAL HEALTH DISORDERS

Module 4 Discussion

Schizophrenia

For the discussion boards this term  please include:

Any differential diagnoses

Your diagnosis and reasoning

Any additional questions you would have asked

 Medication recommendations along with your rationale. Note possible side effects or issues  to address if attempting to obtain consent.

Any labs and why they may be indicated

Screener scales or diagnostic tools that may be beneficial

Additional resources to give  (Therapy modalities, support groups, activities, etc.)

Case Study 1

Dusty

Dusty a 21 year old, somewhat frail looking, Caucasian male who appeared quitedisheveled and agitated upon presentation at the admissions department at Specialty Hospital.  He is 5’ 10” and weighs approximately 140 lbs (BMI=20.1).  His attitude was friendly.  His mother accompanied him to hospital. 

Chief complaint:  “I can’t get it together.”  “I can hear through metal.”  Dusty was hyper-alert, orientation was to self and mother.  He did not know what city he was in and was confused as to the date and day of week.  His thought processes were chaotic and circumstantial with bizarre and paranoid ideation.  Speech was disorganized.  Long and short- term memory was moderately affected.  He was cooperative and at times quite bizarre, in the evaluation process.  Concentration was poor – he was very distractible.  Emotional state was one of moderate agitation.  Speech was somewhat pressured and he had poor eye contact.  Visual and auditory hallucinations are present and were in the past two weeks.  He was intermittently responding to these internal stimuli during the evaluation.  

Dusty denies suicidal ideation, although he reported homicidal ideation toward his girlfriends X-husband.  He was unable to sit still during the evaluation process.  He would pace, lie down on the couch, look out door suspiciously and pace again. 

Patient states:  “all this began on Father’s day” (although mother states three to

four weeks ago) when he “lost” his pickup truck.  The previous evening, he states, that he drank some Jack (Jack Daniels whiskey) and smoked some marijuana.  States he was “raped” by a man who he hitched hiked with while looking for his vehicle.  Police officers found Dusty, wandering barefoot and disheveled, looking for his vehicle.  His feet were bleeding and quite raw from aimlessly wandering barefooted.  He was taken to the home of his mother, where had been living, since the University was out for the summer. 

Dusty had a four- year scholarship at a moderately large University.  This last semester he states, he had done poorly because he “couldn’t get it together, I was taking some drugs and drinking….but that didn’t seem to help.” 

Mother reports that while at her home, he exhibited bizarre behaviors:  such as, going outside and laying in the flower- bed, laying in a dry tub and sticking his 

chest with old lancets, that mother had used for testing blood sugars.  When asked

what he was doing he stated that he was “testing himself for heart trouble.”  His mother reported that his appetite of late has been poor. 

Dusty states that he is heterosexual but qualifies his statement with, “I guess I’m open to anything.”  Dusty cannot be viewed as a reliable historian now.                                                       

History

Dusty was the youngest of seven children.  He has six siblings, four sisters and two brothers.  His father has been described as a physically violent man with an alcohol problem.  He died two years ago from cirrhosis of the liver.  Dusty has no contact with his biological father.  Mother was physically abused, although denies that father ever abused children.  Mother divorced her husband, when Dusty was nearing age two, and at this time placed all seven children in the Masonic home.  The children would visit their mother on some weekends and a month during the summer.  Approximately three years after the divorce their mother married again.  Dusty expressed that he liked his step father…”the only father that I knew”.  The children continued to live at the Masonic home despite mother’s re-marriage.  Dusty and one sister report being both physical and sexual abused by a house parent at the home.  Mother states that the children never told her that this occurred.

Rusty reports that he has a long history of drug and alcohol abuse.  At age 11, he began smoking marijuana at age eleven, at fifteen he started to drink alcohol.  By age twenty- one, he was using Ice, Ecstasy, GHB and anything else that was available. 

In April, Dusty was terminated from his job at a metal factory and shortly began looking for another job, with no success.  Rusty had a four- year scholarship to College.  During this past year, his grades have suffered and the scholarship is no longer available.  His estimated intelligence is above – average.  He met his girlfriend in the last four months.  She was married and pregnant. 

Dusty’s delusions revolve around being able to hear thru stee1 and “being called” into the military to save Iraq.  He quotes the Bible and states that the Book of Numbers gives him permission to kill, if he were in the military.  His goals in life are very unrealistic – at one moment wanting to be a philosopher, a military soldier, a priest.

Dusty relates that the “voices” started (hallucinations) after reading the Remembrance magazine.  “The women that were in there shot me – we were having a fireside chat.”  States that each time he looks in the mirror he hears voices stating, “That’s what ice cream is for”.  He has denied any command hallucinations or voices, which negate him.     

Dusty reports no physiological illnesses or any prescribed medications.  He states that he has been in good physical health.  He reports intermittent sleep problems.  A physical done (by an FNP), at admission, substantiates his report.  Only injuries noted were abrasions to feet.

 A drug screen, CBC, CMP, UA, RPR, TSH, B12/Folic Acid, and HIV screen were all within normal limits.  

Case Study 2

25  year  old woman found unresponsive

  History of present illness:

  A 25 year old woman is brought to the ER, apparently unresponsive. She was found, lying on a park bench, by the police, and when they could not arouse her, they called an ambulance.  Her vital signs are normal: B/P=115/80, HR=76, temp. 98.6F and respiratory rate =16. Physical examination reveals no signs of trauma or obvious injury. The patient is gaunt and looks malnourished. Her eyes are closed, and she does not respond to voice or sternal rub. Strangely, when the ER physician tries to move her arms, he meets strong resistance and moves her arm to a new position only with great effort. Even more to his surprise, he finds that her arm stays in the new position, even after he releases it.

Luckily, the patient had identification in her purse, which, with some prying, was taken from her on admission.  Her mother is contacted.  Mother states that she is frightened after hearing her daughter’s condition because nothing like this has happened to her before.  The mother is relieved that her daughter was found. Until about 3 months ago, the pt. was living with her mother but not had been seen since then.  Mother describes her as a cooperative child who never made unreasonable demands and was quiet and introspective while growing up.According to mother, the pt. had finished high school and had started classes at a community college.  However, she had stopped school after one semester because of poor grades.  The patient spent most of her time doing clerical work in the family real estate business.  She had become more withdrawn over the past year, but mother interpreted this behavior as being “a little down” because her only friend had graduated from college and was now engaged to be married.  Approximately 7 months ago, the patient’s mother became more concerned because her daughter had become more reclusive, missing work and often spending many days at a time in her room.  She would come out only to eat a few morsels of food and then quickly retreat to the confines of her room.  At that point in time, she states that her daughter appeared preoccupied with whether the food she was eating had been “killed in a morally acceptable way”.  She expected her daughter to “snap out of it” but eventually told her she was going to take her to see a doctor.  The next morning the patient disappeared (3 mo. Before current presentation).

Past Psychiatric Hx:

According to mother, the patient has no history of psychiatric illness and, as far as she knew, never used drugs.  The mother recalls a cousin with mental illness who is now in an “institution”.

Past Medical Hx:

The patient has no medical problems, takes no medication, and has no known allergies.

Laboratory:

WBC—6,000

Hemoglobin…13.3

Sodium…141

Potassium…4.1

Calcium…10.3

Mg…2.0

Phosphorus…2.1

Arterial blood gasses…WNL

Pulse oximetry…97% on room air

Diagnostic Testing:

Stat CT scan…reveals no evidence of bleeding, mass or infarct

CSF (lumbar puncture) was clear

no signs of infection, cultures and PCR pending.

Mental Status Exam:

The pt. is a slightly cachectic looking woman, lying on a stretcher, with eyes shut. She does not respond to questions or touch.  She does not move spontaneously, and when placed, her extremities hold their position.

Limba have cogwheel rigidity on flexion and extension.  There is no spontaneous speech, or thought content.  Orientation cannot be assessed, nor can judgment or insight. 

 

 

MSN675 MANAGEMENT OF PSYCHIATRIC MENTAL HEALTH DISORDERS

Module 5 Discussion  

PTSD/ODD/Conduct disorders

Discuss and answer questions related to the case presentation. 

For the discussion boards this term  please include:

Any differential diagnoses

Your diagnosis and reasoning

Any additional questions you would have asked

 Medication recommendations along with your rationale. Note possible side effects or issues  to address if attempting to obtain consent.

Any labs and why they may be indicated

Screener scales or diagnostic tools that may be beneficial

Additional resources to give  (Therapy modalities, support groups, activities, etc.)

Case Study 1

33 Y/O Male

History of Present Illness:

A 33 year old male is brought to the psychiatric department by police after he attacked another man in a bar and threatened to “rip (your) throat out with (my) bare hands”.  The pt. apparently returned from the restroom in the bar to find the man putting an arm around his girlfriend.  The pt. states that he immediately became ‘ENRAGED” and began to scream obscenities.  The shouting quickly escalated into a full blown bar brawl, and the police intervened when the patient wrapped his hands around the man’s throat and pinned him against the bar.

The pt. admits to numerous incidents of this nature and has found himself in fights several times each year since late adolescence.  Two months ago, he was arrested for smashing a car window with a baseball bat when the man “cut him off” on the highway.  He was also fired from several jobs in his late 20’s due to his “hot temper” with coworkers who were trying to “slight him”.  The pt. believes that his actions are sometimes unreasonable, but the combination of heightened energy, racing thoughts, and anger makes his urges nearly impossible to resist.

The pts. girlfriend states that he is a fun loving and charming man between episodes but starts arguments with her approximately twice a week.  She claims that during his verbal attacks he will often make demeaning and devaluing remarks about her.  On several occasions he has broken her personal belongings during trivial arguments.  The pt. acknowledges that he regrets these episodes, but they usually subside within a half hour and provide an instant sense of relief.

Past Psychiatric History:

No psychiatric history or past use of psychiatric medications is reported.  The pt. denies symptoms of a mood disorder.  He admits to 1 or 2 alcoholic drinks per week and a history of marijuana experimentation in his late teens.

Mental Status Exam:

The pt. appears well built and sharply dressed and looks his stated age.  He is awake, alert and oriented in all spheres.  Behavior is appropriate, and eye contact is good.  Speech is clear and coherent with normal rate, rhythm, and volume.

Mood is euthymic, and affect is full.  Thought process is logical and goal directed.  Thought content does not include delusions, ideas of reference, paranoid ideation, suicidal, or homicidal ideation.  Impulse control is poor, as noted by his recent violent outbursts.  Insight is limited because he does not recognize the maladaptive nature of his behavior.  Judgment is impaired, as evidenced by his inability to behave in asocially accepted ways.  Reliability is fair.

Labs:

Na = 141, K=4.2, Chloride=106, carbon dioxide =23, blood urea nitrogen=9, creatinine=0.6, glucose=91.

Blood alcohol level and urine tox are negative.

Diagnostic Testing:

CT of the head shows no sign of mass, lesion or bleeding.  Electroencephalogram is unremarkable without signs of slowing or seizure foci.

Physical Exam:

The man appears healthy, and the exam is within normal limits without remarkable findings.

 

Case Study 2

A 38 year old single mother of a six year old biological son was referred by her PCP as an emergency to a Psychiatric NP. Upon entering the waiting room the woman looked exhausted and disheveled. Her straight short blond hair looked uncombed and she was dressed in a worn sweat suit. She was accompanied to the session by her best friend who drove her to the session. Although the woman’s mood seemed tired but controlled while filling out the admission papers, upon telling her story the woman immediately began to sob.

The woman described that at 8:30PM three days ago in the evening her house was entered by a man whom she did not recognize. She was bound, gagged and intermittently raped over the next 2 and ½ hours. Prior to his entry the woman had been in her study working on documents which she had brought home from work. Upon walking out of her study the woman confronted the man standing in her kitchen. At this point she realized that the she had left the door open as it was a warm night and, “everyone in the neighborhood” trusts each other.

After 2 ½ hours of the man alternating between pacing her house and raping her he left her after he unbound her. She remembers feeling too scared to scream, feared that he would kill her,  yet also feeling grateful that her son was not at home but staying overnight with his relatives.

After the man left her house the woman called her best friend who begged her to call the police but she refused. She was afraid that the incident would be put in the newspaper if she called the police. She describes showering for 1 hour, scrubbing herself over and over. She then lay awake the entire night until her PCP saw her in the morning who referred h