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Case Study essay paper

Case Study

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· Answer questions # 1, 2, 3 Based on this case study

 

Chief Complaint

“My daughter has had a bad fever, and now she is having trouble breathing, and  albuterol doesn’t help.”

HPI

Terri Collins is an 8-year-old African-American girl who presents to the ED with a 2-day history of fevers, malaise, and nonproductive cough. The mother gave  acetaminophen and  ibuprofen to help control the fever. Mother stated that “a lot of other kids in her class have been sick this fall, too.” Terri started having trouble breathing the morning of admission, and the mother gave her  albuterol, 2.5 mg via nebulization twice within an hour. Terri still sounded wheezy to the mother after the  albuterol, and Terri stated it was “hard to breathe.” Terri was previously well controlled regarding asthma symptoms. Previous clinic notes reported symptoms during the day only with active play at school or at home and rare nighttime symptoms. She uses PRN  albuterol to help with symptoms after playing. Her assessment in the emergency department revealed Terri to have labored breathing, such that she could only complete four- to five-word sentences. She had subcostal retractions, tracheal tugging with tachypnea at 54 breaths/min. Her other vital signs were a heart rate of 160 bpm, blood pressure of 115/59, temperature of 38.8°C, and a weight of 22.7 kg. The initial  oxygen saturation was 88%, and she was started on  oxygen at 1 L/min via nasal cannula. Bilateral expiratory and inspiratory wheezes were noted on examination. A chest x-ray revealed a right lower lobe consolidation consistent with pneumonia and possible effusion. After receiving three  albuterolipratropium nebulizations, her breath sounds and oxygenation did not improve, so she was started on  albuterol via continuous nebulization at 10 mg/hr and her  oxygen was titrated to 3 L/min. She was also given a dose of 25 mg IV  methylprednisolone and a dose of 600 mg IV magnesium sulfate. Terri was then transferred to the PICU for further treatment and monitoring.Case Study

PMH

Asthma; last hospitalization 4 years ago, and has had two courses of oral corticosteroids in the past year

FH

Asthma on father’s side of the family

SH

Lives with mother, father, and two siblings, both of whom have asthma. There are two cats and a dog in the home. Father is a smoker but states that he tries to smoke outside and not around the kids. She is in the second grade and is very active on the playground.

Meds

Albuterol 2.5 mg nebulized Q 4–6 H PRN wheezing

Fluticasone propionate 44 mcg MDI two puffs BIDCase Study

Acetaminophen 160 mg/5 mL—10 mL Q 4 H PRN fever

Ibuprofen 100 mg/5 mL—10 mL Q 6 H PRN fever

All

NKA

ROS

(+) Fever, cough, increased work of breathing

Physical Examination

Gen

Alert and oriented but in mild distress with difficulty breathing

VS

Case Study

BP 125/69, P 120, T 37.9°C, RR 40, O2 sat 94% on 3 L/min nasal cannula

Skin

No rashes, no bruisesCase Study

HEENT

NC/AT, PERRLA

Neck/LN

Soft, supple, no cervical lymphadenopathy

Chest

Wheezes throughout all lung fields, still with subcostal retractionsCase Study

CV

RRR, no m/r/g

Abd

Soft, NT/ND

Ext

No clubbing or cyanosis

Neuro

A&O, no focal deficitsCase Study

Labs

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Na 141 mEq/L WBC 34.2 × 103/mm3
K 3.1 mEq/L  Neut 91%
Cl 104 mEq/L  Lymph 5%
CO2 29 mEq/L  Mono 4%
BUN 16 mg/dL RBC 5.07 × 106/mm3
SCr 0.52 mg/dL Hgb 13 g/dL
Glu 154 mg/dL Hct 41%
  Plt 310 × 103/mm3

Respiratory viral panel nasal swab: positive for influenza A

Chest X-RayCase Study

RLL consolidation

Assessment

Asthma exacerbation with viral pneumonia

Questions

1. What additional information is needed to fully assess this patient?

2. What nondrug therapies might be useful for this patient?

3. Develop a plan for follow-up that includes appropriate time frames to assess progress toward achievement of the goals of therapy.Case Study

Case Study essay paper

Case Study

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NRNP 6635 Case History Reports

Use these case histories to supplement the information about the patients in the video case studies.

Table of Contents

Week 3: Mood Disorders………………………………………………………………………………………….. 3

Training Title 2 ……………………………………………………………………………………………………………….3

Training Title 8 ……………………………………………………………………………………………………………….3

Training Title 18 ……………………………………………………………………………………………………………..3

Training Title 28 ……………………………………………………………………………………………………………..4

Training Title 38 ……………………………………………………………………………………………………………..4

Training Title 43 ……………………………………………………………………………………………………………..5

Training Title 150 ……………………………………………………………………………………………………………5

Training Title 118 ……………………………………………………………………………………………………………6

Training Title 144 ……………………………………………………………………………………………………………6

Week 4: Anxiety Disorders, PTSD, and OCD …………………………………………………………………. 7

Training Title 15 ……………………………………………………………………………………………………………..7

Training Title 21 ……………………………………………………………………………………………………………..7

Training Title 37 ……………………………………………………………………………………………………………..8

Training Title 40 ……………………………………………………………………………………………………………..8

Training Title 55 ……………………………………………………………………………………………………………..8

Training Title 85 ……………………………………………………………………………………………………………..9

Training Title 95 ……………………………………………………………………………………………………………..9

Week 7 Schizophrenia and Other Psychotic Disorders; Medication-Induced Movement Disorders …………………………………………………………………………………………………………….. 10

Training Title 9 …………………………………………………………………………………………………………….. 10

Training Title 24 …………………………………………………………………………………………………………… 10

Training Title 29 …………………………………………………………………………………………………………… 10

Training Title 134 …………………………………………………………………………………………………………. 11

Week 8 Substance-Related and Addictive Disorders ……………………………………………………. 11

Training Title 82 …………………………………………………………………………………………………………… 11

Training Title 114 …………………………………………………………………………………………………………. 12

Training Title 151 …………………………………………………………………………………………………………. 12

Week 10 Neurocognitive and Neurodevelopmental Disorders ………………………………………. 13

Training Title 48 …………………………………………………………………………………………………………… 13

Training Title 50 …………………………………………………………………………………………………………… 13

Week 3: Mood Disorders

Training Title 2

Name: Ms. Natalie Crew Gender: female Age:17 years old T 97.4 P-82 R-1 20 128/84 Ht 5’2” Wt 192lbs Background: Recently started an accelerated high school business program in Chicago, Illinois after growing up and living in New Orleans her whole life. Grew up with both parents and four brothers. Currently lives in on a specialty high school campus dormitory. Currently a full-time student and works part time in the local coffee shop. Not married, currently single. She has no previous psychiatric history; takes no medications. There is history of depression, denied substance use history for her or family. No legal hx NKDACase Study

Symptom Media. (Producer). (2016). Training title 2 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-2

Training Title 8

Name: Mrs. Abrianna Tilman Gender: female Age: 27 years old T- 98.6 P- 88 R 18 154/92 Ht 5’1 Wt 230lbs Background: Recently had her first child two months ago. Currently married; stay at home mother after working in community library for 5 years. Grew up with her mother after her parents divorced when she was 16; has two sisters in Troy, Alabama. Completed education through bachelor’s level, majoring in English Literature. No previous suicidal gestures. Brother committed suicide via GSW. She denied drugs/alcohol; brother was addicted to methamphetamines. Hx of HTN-prescribed Trandate 100mg twice daily, admits to missing doses due to forgetting. No legal hx. Allergies: PCN Symptom Media. (Producer). (2016). Training title 8 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-8Case Study

Training Title 18

Name: Ms. Rosario Campbell Gender: female Age:25 years old T-97.7 P-70 R-18 118/72 Ht 5’3 Wt 123lbs Background: Currently living off-base in El Paso, Texas, active duty in the Army, MOS 92M Mortuary Affairs Specialist. Grew up in McAllen TX with both parents and one brother. Completed education through high school. Currently partnered. No children. Mother history of

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depression; brother hx of cannabis use. No medical history. No legal hx; allergy: cipro previous medication trials: sertraline, fluoxetine both with good effects when taking.Case Study

Symptom Media. (Producer). (2017). Training title 18 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-18 Training Title 28

Name: Mrs. Ada Carson Gender: female Age: 54 years old T- 97.6 P- 94 R 22 162/84 Ht 5’5 Wt 144lbs Background: Currently living in Sioux Falls, South Dakota, working full-time as a contract negotiator in a financial company. Has an MBA. Lives with her husband and two teenage twin sons. Born and raised in Trenton, NJ, with her father and two brothers, her mother deceased when she in MVA when she was 12 years old. Brother has depression; mother has history of being a “functioning alcoholic”. Recently informed by her PCP she has a “fatty liver.” Allergies: codeine Symptom Media. (Producer). (2016). Training title 28 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-28Case Study

Training Title 38 Name: Mr. Elijah Loman Gender: male Age:18 years old T- 98.3 P- 93 R 22 118/68 Ht 5’7 Wt 149lbs Background: Currently lives with his sister and two parents in Durham, NC. Not currently employed. Completed high school, not currently in school. Hx of treatment for mood disorder began age 15, previous trials of risperidone, quetiapine off and on, side effects of wt. gain. Has hx of a six-day hospitalization one year ago after found wandering at night in the mall parking lot without clothes. He refused medication due to previous experiences. Not currently partnered. He has been sexually inappropriate with comments to female neighbors; pulled his pants down in the mall. Denies any recent alcohol or substance use. Father has history of bipolar disorder. No history of self-harm behaviors, no family suicides. Mother reports he has slept 4-5 hours in past week, up spending money buying and playing new video games and says he is writing a book on how others can be a video game master. Appetite is decreased. No medical hx; Hx of vandalism as a juvenile. Has pending court date for indecent exposure. Allergies: latex Symptom Media. (Producer). (2016). Training title 38 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-38Case Study

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Training Title 43 Name: Mr. Elijah Loman Gender: male Age:20 years old T- 97.2 P- 84 R 18 118/68 Ht 5’7 Wt 156lbs Background: Currently lives with his sister and her husband who are his legal guardians as parents deceased when he was 15 and he was deemed to need a fiduciary and guardian by the court system. Not currently employed. Completed high school, not currently in school. Hx of treatment for mood disorder began age 15, previous trials of Depakote, Quetiapine off and on, side effects of akathisia. Has hx of a multiple hospitalization, last was 4 months ago when he exposed his genitals to girls at the mall. . Not currently partnered. He is currently in hospital admitted one week ago, was initiated on lithium 300mg po three times daily and risperidone 1mg at bedtime. Denies any recent alcohol or substance use. Paternal uncle has history of bipolar disorder. No history of self-harm behaviors, no family suicides. Appetite is decreased. No medical hx; hospital admission labs within normal ranges, UDS negative; Hx of truancy as a juvenile. Has pending court date for indecent exposure. Allergies NKDA Symptom Media. (Producer). (2016). Training title 43 [Video]. https://video-alexanderstreet-Case Study com.ezp.waldenulibrary.org/watch/training-title-43

Training Title 150

Name: Ms. Cheyenne Lisenbe Gender: female Age:18 years old T- 97.4 P- 94 R 22 136/86 Ht 5’2 Wt 121 Background: Currently living with her parents in Locust Grove, Oklahoma along with two younger sisters and 1 older brother. She is a senior in high school, not currently partnered, reports she is bisexual, lately hyper-sexual reporting increase of unprotected sex. She has been stealing money out of her grandmother’s purse to buy clothes, shoes, purses, “and just other things. She has history of treatment since age 9 for conduct disorder, depression, history of taking citalopram which worsened her irritability, aggression, impulsivity. She has been in a 90- day teen residential mental health facility discharged three months ago with lithium 300mg in am and 600mg at bedtime, aripiprazole 2.5mg in the morning. When discharged, her labs were within normal ranges and urine toxicology negative. She was positive for cannabis upon admission. Her parents believe she is hiding her medication as she has made comments “they slow me down; they make me not think fast” She has hx of domestic violence toward her older brother with juvenile assault charge. No current legal issues. Her grandmother has hx of bipolar disorder; her mother and her maternal aunt have anxiety. She is sleeping 2-3hrs/24 hrs. Reports her appetite “ravishing.” She has no medical issues; has Nexplanon implant; hx of self-harm with cutting, last engaged in the behavior 6 months ago. Symptom Media. (Producer). (2018). Training title 150 [Video]. https://video-alexanderstreet-Case Study com.ezp.waldenulibrary.org/watch/training-title-150

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Training Title 118 Name: Mr. Connor Walsh Gender: male Age: 57 years old T- 97.2 P- 94 R 20 156/88 Ht 5’8 Wt 163lbs Background: Born and raised in Peru Indiana Is staying at a shelter after being homeless in MacArthur Park for 1 year in Los Angeles. He lost his apartment and his job working part-time at Home Depot. Enjoys playing music. He has long hx of mental health treatment since age 19. Previous medication trials include lithium (was effective), Depakote (gastric upset), aripiprazole (akathisia), risperidone (hyperprolactinemia), haloperidol (dystonia), quetiapine (didn’t give a fair trial), Poor historian. divorced once, reports being gay, no children; estranged from only living sister, parents deceased. He is not sure of his family mental health or substance use history but feels like he is most like his aunt, she has history of mental health treatment “but I’m not sure for what.” States that he got a master’s degree in music theory at Stanford. Admits to 3-6 drinks of alcohol when “playing music in the clubs”, denied illicit drugs, has history of intentional drug overdose at age 22, history of 8 inpatient psychiatric hospitalization, most recent was 8 months ago. hx of one detox admission 15 years ago Allergies: bee stings Symptom Media. (Producer). (2018). Training title 118 [Video]. https://video-alexanderstreet-Case Study com.ezp.waldenulibrary.org/watch/training-title-118

Training Title 144 Name: Ms. Amy Hartford Gender: female Age: 26 years old T- 98.2 P- 70 R 18 128/76 Ht 5’0 Wt 152lbs Background: Currently lives in Scottsdale, AZ, divorced with two children a daughter age 8 and son age 4. Born and raised in Mesa, AZ with her mother and two sisters Works as paralegal, has an associate degree; no legal hx; allergic to dicyclomine; history of rosacea Symptom Media. (Producer). (2018). Training title 144 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-144

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Week 4: Anxiety Disorders, PTSD, and OCD Training Title 15

Name: Mr. Ralph Newsome Gender: male Age:19 years old T- 97.0 P- 70 R 18 116/68 Ht 5’9 Wt 175lbs Background: Lives in Columbus, OH with his dog Chance, only child. Parents live locally. Works part time in Construction. Not currently partnered. No previous psychiatric history. Symptoms began in the last 2 months when he discovered he is being activated with the Navy Reserves. His MOS is CM3 Construction Mechanic; no medical illnesses, no legal hx. Allergies: NKDA; sleeps 8hrs; appetite good Symptom Media. (Producer). (2017). Training title 15 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-15

Training Title 21 Name: Sergeant Berry Sullivan Gender: male Age:27 years old T- 98.8 P- 86 R 18 B/P 122/7 Ht 5’8 Wt 160lbs Background: He entered the military just after high school and did three long tours of duty in warzones. He separated from active duty in the Marines (MOS 0800 Field Artillery) six months ago after eight years of service. He is engaged to be married in 8 months and is using his GI Education Bill to attend online college for accounting. He said he grew up poor and would not do much else if he didn’t go into the military. He denies ever using any drugs and avoids alcohol because his father was “abusive when he was drunk.” Father is still alive, unwell (DM, cirrhosis, HTN), still drinking. Paternal grandfather was also a veteran and suffered depression at times though he never told anyone except the patient because of their combat connection. He has one younger brother and one older sister. He lives in a different state, approximately five hours from his parents and siblings. After the military, he and his fiancé moved because she got a much better opportunity. They want kids someday. Has service-connected asthma, seasonal allergies; no hx of psychiatric or substance use treatment. Symptom Media. (Producer). (2016). Training title 21 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-21Case Study

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Training Title 37

Name: Mr. Luca Esposito Gender: male Age:21 years old T- 97.4 P- 112 R 22 122/68 Ht 6’1Wt 198lbs Background: Lives alone in Orlando, FL raised by parents in Buffalo, NY, only child. He is a full- time student obtaining a degree for graphic design. works part-time as Uber driver. Has a girlfriend from high school. No previous psychiatric history. No medical illnesses; no history of psychiatric treatment; denied drugs or alcohol; Allergies: NKDA; sleeps 6 hrs.; appetite eats 3 meals/day, likes to keep a routine schedule. Symptom Media. (Producer). (2016). Training title 37 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-37Case Study

Training Title 40 Name: Ms. Connie Weidre Gender: female Age: 53 years old T- 99.0 P- 102 R 24 156/86 Ht 5’4 Wt 1lbs73 Background: Lives with her husband in Memphis, TN, has one daughter age 25. She has never worked. Raised by mother, she never knew her father. Mother with hx of generalized anxiety and was verbally abusive, abused benzodiazepines; no substance hx for patient. No previous psychiatric treatment. Has one glass red wine with dinner. Sleeps 12-13 hrs.; appetite decreased. Has overactive bladder, untreated. Allergic to Zofran; complains of headaches, takes prn Tylenol, has diarrhea 2-3 times weekly, takes OTC Imodium. Symptom Media. (Producer). (2016). Training title 40 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-40

Training Title 55 Name: Matilda Johnson Gender: female Age: 8 years old T-98.0 P 70 R 24 B/P 110/68 Ht 45 inches Wt 57lbs Vaccinations are up to date, on target with developmental milestones. Appetite, she is a picky eater per mom. NKDA Symptom Media. (Producer). (2017). Training title 55 [Video]. https://video-alexanderstreet-Case Study com.ezp.waldenulibrary.org/watch/training-title-55

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Training Title 85

Name: Mrs. Isla Flanagan Gender: female Age: 47 years old T- 98.0 P- 82 R 18 136/62 Ht 5’0 Wt 123lbs Background: Born and raised in Northern Ireland, parents brought her and her one sister to U.S. when she was 15 to go to U.S. university where she met her husband. They live in Charleston, SC. She obtained her master’s degree in education; no history of mental health or substance use treatment, no family history. Her husband reported a recent school shooting nearby 3 weeks ago “flipped a switch” in her. She is watching the news 24/7, barely sleeping, and even when she does, it is only a few hours, Appetite is decreased. Hx of hysterectomy, NKDA, no legal hx. Symptom Media. (Producer). (2017). Training title 85 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-85

Training Title 95

Name: Ms. Serenity Jackson Gender: female Age: 24years old T- 97.5 P- 80 R 18 118/74 Ht 5’2 Wt 136lbs Background: Born and raised in Gainesville, FL with her mother and 4 older brothers; her mother has hx of panic disorder, 2 brothers hx of cannabis; father abandoned the family when she was 3 years old. One brother is in prison for burglary. no previous mental health treatment, no medications; NKDA; no legal hx; sleeping 9 hrs.; Appetite is good. She has an associate of arts degree and works for Leaders furniture warehouse. She has DX of diabetes since age 8. She recalls having great difficulty with her medical condition (uncontrolled blood sugar, fighting with mother over needle sticks, “kids want candy, and I was so different because of my diet”). She recalls having a difficult relationship with her mother who was a nurse and really worked hard to control her daughter’s diabetes. She is not in a relationship, identifies as lesbian but has not come out to the family. Only her closest co-workers know She stated, “I don’t see why I would, they wouldn’t understand, and this is not important right now.” Symptom Media. (Producer). (2018). Training title 95 [Video]. https://video-alexanderstreet-Case Study com.ezp.waldenulibrary.org/watch/training-title-95

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Week 7 Schizophrenia and Other Psychotic Disorders; Medication- Induced Movement Disorders Training Title 9 Name: Ms. Fatima Branning Gender: female Age: 28 years old T- 98.4 P- 82 R 18 124/74 Ht 5’0 Wt 118lbs Background: Raised by parents, lives alone in Coronado, CA. Only child. Works as an administrative assistance in car sales, has a bachelor’s in hospitality. Has medical history of scoliosis, currently treated with chiropractic care. Guarded and declined to discuss past psychiatric history. Denied family mental health issues, declined to allow you to speak to parents for collaborative information. Allergies: latex; menses regular, no birth control Symptom Media. (Producer). (2016). Training title 9 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-9

Training Title 24 Name: Ms. Jess Davies Gender: female Age: 30 years old T- 98.6 P- 86 R 20 120/70 Ht 5’2 Wt 126lbs Background: Jess is brought for evaluation by her 2 roommates who are concerned with behaviors. She had some issues with depression after aunt died but worsened in the 12 days after she witnessed her brother killed via GSW in a gas station burglary. She is estranged from her parents and her brother was her only sibling. She is only sleeping 2 hours/24hrs; she will only eat canned foods. She smokes cannabis daily since she was 17 and goes out on weekdays couple times with her roommates and has couple drinks of beer. She was prescribed alprazolam 1mg twice daily as needed by her PCP for 15 days. She works in a bakery. Allergies: medical tapeCase Study

Symptom Media. (Producer). (2016). Training title 24 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-24

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

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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). Training title 29 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-29

Training Title 134

Name: Mrs. Patricia Warren Gender: female Age: 42 years old Background: Patricia was brought in under a emergency evaluation order after her best friend, Felicia, after the police for Patricia locking herself in a closet and screaming loudly for over an hour. EMS was able to calm her with a small dose of Ativan enroute to the emergency department. This is Patricia’s third presentation to the emergency room in 2 weeks. She had one psychiatric hospitalization around this same last year. No self-harm behaviors but has assaulted other in the past. No hx of TBI. Sleeps 1–2-hour increments for total of 6 hrs. daily, refuses to sleep at night. Refused vitals, wt., refuses labs, not cooperative. She obtains SSDI. She lives in Cameron, Montana. She denies ever using any drugs and drinks one glass wine weekly. She has a sister who is five years older, both parents deceased in the last three years. She has no children, her husband is out of town, truck driver. Family history includes that her father had two previous inpatient psychiatric hospitalizations for paranoia Mother had history of bipolar depression. Paternal grandmother had “shock therapy”. Denies history of trauma experience, but her friend reports parents death was extremely difficulty for Patricia. no current legal charges. dropped out of high school in 11th grade, was pregnant and had abortion. allergies: ClozarilCase Study

Symptom Media. (Producer). (2018). Training title 134 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-134

Week 8 Substance-Related and Addictive Disorders Training Title 82 Name: Lisa Tremblay Gender: female Age: 33 years old T- 100.0 P- 108 R 20 180/110 Ht 5’6 Wt 146lbs

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https://video-alexanderstreet-com.ezp.waldenulibrary.org/watch/training-title-134
https://video-alexanderstreet-com.ezp.waldenulibrary.org/watch/training-title-134
Background: Lisa is in a Naples, FL detox facility thinking about long term rehab. She is considering treatment for her Hep C+ but needs to get clean first. She has been abusing opiates, approximately $100 daily. She admits to cannabis 1–2 times weekly (“I have a medical card”), and 1/2 gallon of vodka daily. She has past drug paraphernalia possession arrest. Her admission labs. abnormal for ALT 168 AST 200 ALK 250; bilirubin 2.5, albumin 3.0; her GGT is 59; UDS positive for opiates, THC. Positive for alcohol or other drugs. BAL .308; other labs within normal ranges. She reports sexual abuse as child ages 6-9 perpetrator being her father who went to prison for the abuse and drug charges. She is estranged from him. Mother lives in Maine, hx of agoraphobia and benzodiazepine abuse. Older brother has not contact with family in last 10 years, hx of opioid use. Sleeps 5-6 hrs., appetite decreased, prefers to get high instead of eating. Allergies: azithromycin Symptom Media. (Producer). (2017). Training title 82 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-82

Training Title 114

Name: Ally Chen Gender: female Age: 44 years old Background: Only child, raised by parents in Philadelphia, PA. Has PhD in biology and master’s degree in high school education (8–12). Her supervisor has asked the school EAP counselor to intervene with concerns regarding potential substance use in effort to facilitate getting her help and be able to retain her. She is divorced, has a 4-year-old son who lives with his father. Appetite healthy, sleeping 9 hours/24 hrs., wakes 2-3 times during the night. Denied drug use. had DUI when she was age 21. Symptom Media. (Producer). (2018). Training title 114-2 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-114-2

Training Title 151 Name: Daniela Petrov Gender: female Age:47 years old T- 98.8 P- 84 R 20 B/P 132/90 Ht 5’8 Wt 128lbs Background: Moved to Everett, Washington from Russia with her parents when she was 16 years old. Currently lives in Boise, Idaho. She has younger 1 brother, 3 older sisters. Denied family mental health or substance use issues. No history of inpatient detox or rehab denied self-harm hx; Menses regular. uses condoms for birth control Has fibromyalgia. She works part time cashier at Save A Lot Grocery Store. Dropped out of high school in 10th grade. Sleeps 5-6 hours on average, appetite good. Symptom Media. (Producer). (2018). Training title 151 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-151

https://video-alexanderstreet-com.ezp.waldenulibrary.org/watch/training-title-82
https://video-alexanderstreet-com.ezp.waldenulibrary.org/watch/training-title-82
https://video-alexanderstreet-com.ezp.waldenulibrary.org/watch/training-title-114-2
https://video-alexanderstreet-com.ezp.waldenulibrary.org/watch/training-title-114-2
https://video-alexanderstreet-com.ezp.waldenulibrary.org/watch/training-title-151
https://video-alexanderstreet-com.ezp.waldenulibrary.org/watch/training-title-151
Week 10 Neurocognitive and Neurodevelopmental Disorders Training Title 48 Name: Sarah Higgins Gender: female Age: 11 years old T- 97.4 P- 58 R 14 98/62 Ht 4’5 Wt 65lbs Background: no history of treatment, developmental milestones met on time, vaccinations up to date. Sleeps 9-10hrs/night, meals are difficult as she has hard time sitting for meals, she does get proper nutrition per PCP. she has a younger brother. lives with her parents in Washington, D.C. No hx of head trauma. Symptom Media. (Producer). (2017). Training title 48 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-48Case Study

Training Title 50 Name: Harold Brown Gender: male Age:60 years old T- 98.8 P- 74 R 18 134/70 Ht 5’10 Wt 170lbs Background: Has bachelor’s degree in engineering. He dates casually, never married, no children. Has one younger brother. Sleeps 7 hours, appetite good. Denied legal issues; MOCA 28/30 difficulty with attention and delayed recall; ASRS-5 21/24; denied hx of drug use; enjoys one scotch drink on the weekends with a cigar. Allergies Dilaudid; history HTN blood pressure controlled with Cozaar 100mg daily, angina prescribed ASA 81mg po daily, valsartan 80mg daily. Hypertriglyceridemia prescribed fenofibrate 160mg daily, has BPH prescribed tamsulosin 0.4mg po bedtime. Symptom Media. (Producer). (2017). Training title 50 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-50Case Study

https://video-alexanderstreet-com.ezp.waldenulibrary.org/watch/training-title-48
https://video-alexanderstreet-com.ezp.waldenulibrary.org/watch/training-title-48
https://video-alexanderstreet-com.ezp.waldenulibrary.org/watch/training-title-50
https://video-alexanderstreet-com.ezp.waldenulibrary.org/watch/training-title-50
Week 3: Mood Disorders
Training Title 2
Training Title 8
Training Title 18
Training Title 28
Training Title 150
Training Title 118
Training Title 144
Week 4: Anxiety Disorders, PTSD, and OCD
Training Title 15
Training Title 21
Training Title 37
Training Title 40
Training Title 55
Training Title 85
Training Title 95
Week 7 Schizophrenia and Other Psychotic Disorders; Medication-Induced Movement Disorders
Training Title 9
Training Title 24
Training Title 29
Training Title 134
Week 8 Substance-Related and Addictive Disorders
Training Title 82
Training Title 114
Training Title 151
Week 10 Neurocognitive and Neurodevelopmental Disorders
Training Title 48
Training Title 50

Case Study essay paper

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NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template

 

Case Study

 

 

Week (enter week #): (Enter assignment title)

 

Case Study

 

Student Name

College of Nursing-PMHNP, Walden University

NRNP 6635: Psychopathology and Diagnostic Reasoning

Faculty Name

Assignment Due Date

 

Case Study

 

 

 

 

 

 

 

 

 

 

Subjective:

CC (chief complaint):

HPI:

Past Psychiatric History:

· General Statement:

· Caregivers (if applicable):

· Hospitalizations:

· Medication trials:

· Psychotherapy or Previous Psychiatric Diagnosis:Case Study

Substance Current Use and History:

Family Psychiatric/Substance Use History:

Psychosocial History:

Medical History:

 

· Current Medications:

· Allergies:

· Reproductive Hx:

ROS:

· GENERAL:

· HEENT:

· SKIN:Case Study

· CARDIOVASCULAR:

· RESPIRATORY:

· GASTROINTESTINAL:

· GENITOURINARY:

· NEUROLOGICAL:

· MUSCULOSKELETAL:

· HEMATOLOGIC:Case Study

· LYMPHATICS:

· ENDOCRINOLOGIC:

Objective:

Physical exam: if applicable

Diagnostic results:

Assessment:

Mental Status Examination:

Differential Diagnoses:Case Study

Reflections:

References

 

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NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Exemplar

INSTRUCTIONS ON HOW TO USE EXEMPLAR AND TEMPLATE—READ CAREFULLY

If you are struggling with the format or remembering what to include, follow the Comprehensive Psychiatric Evaluation Template AND the Rubric as your guide. It is also helpful to review the rubric in detail in order not to lose points unnecessarily because you missed something required. Below highlights by category are taken directly from the grading rubric for the assignment in Weeks 4–10. After reviewing the full details of the rubric, you can use it as a guide.Case Study

In the Subjective section, provide:

· Chief complaint

· History of present illness (HPI)

· Past psychiatric historyCase Study

· Medication trials and current medications

· Psychotherapy or previous psychiatric diagnosis

· Pertinent substance use, family psychiatric/substance use, social, and medical history

· Allergies

· ROSCase Study

· Read rating descriptions to see the grading standards!

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.

· Read rating descriptions to see the grading standards!

In the Assessment section, provide:Case Study

· 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 .Case Study

· Read rating descriptions to see the grading standards!

Reflect on this case. Include: 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.).Case Study

(The comprehensive evaluation is typically the initial new patient evaluation. You will practice writing this type of note in this course. You will be ruling out other mental illnesses so often you will write up what symptoms are present and what symptoms are not present from illnesses to demonstrate you have indeed assessed for all illnesses which could be impacting your patient. For example, anxiety symptoms, depressive symptoms, bipolar symptoms, psychosis symptoms, substance use, etc.) EXEMPLAR BEGINS HERE

CC (chief complaint): A brief statement identifying why the patient is here. This statement is verbatim of the patient’s own words about why presenting for assessment. For a patient with dementia or other cognitive deficits, this statement can be obtained from a family member.Case Study

HPI: Begin this section with patient’s initials, age, race, gender, purpose of evaluation, current medication and referral reason. For example:

N.M. is a 34-year-old Asian male presents for psychiatric evaluation for anxiety. He is currently prescribed sertraline which he finds ineffective. His PCP referred him for evaluation and treatment.

Or

P.H., a 16-year-old Hispanic female, presents for psychiatric evaluation for concentration difficulty. She is not currently prescribed psychotropic medications. She is referred by her therapist for medication evaluation and treatment.

Then, this section continues with the symptom analysis for your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis.Case Study

Paint a picture of what is wrong with the patient. First what is bringing the patient to your evaluation. Then, include a PSYCHIATRIC REVIEW OF SYMPTOMS. The symptoms onset, duration, frequency, severity, and impact. Your description here will guide your differential diagnoses. You are seeking symptoms that may align with many DSM-5-TR diagnoses, narrowing to what aligns with diagnostic criteria for mental health and substance use disorders.Case Study

Past Psychiatric History: This section documents the patient’s past treatments. Use the mnemonic Go Cha MP.

General Statement: Typically, this is a statement of the patients first treatment experience. For example: The patient entered treatment at the age of 10 with counseling for depression during her parents’ divorce. OR The patient entered treatment for detox at age 26 after abusing alcohol since age 13.

Caregivers are listed if applicable.

Hospitalizations: How many hospitalizations? When and where was last hospitalization? How many detox? How many residential treatments? When and where was last detox/residential treatment? Any history of suicidal or homicidal behaviors? Any history of self-harm behaviors?

Medication trials: What are the previous psychotropic medications the patient has tried and what was their reaction? Effective, Not Effective, Adverse Reaction? Some examples: Haloperidol (dystonic reaction), risperidone (hyperprolactinemia), olanzapine (effective, insurance wouldn’t pay for it)Case Study

Psychotherapy or Previous Psychiatric Diagnosis: This section can be completed one of two ways depending on what you want to capture to support the evaluation. First, does the patient know what type? Did they find psychotherapy helpful or not? Why? Second, what are the previous diagnosis for the client noted from previous treatments and other providers. Thirdly, you could document both.Case Study

Substance Use History: This section contains any history or current use of caffeine, nicotine, illicit substance (including marijuana), and alcohol. Include the daily amount of use and last known use. Include type of use such as inhales, snorts, IV, etc. Include any histories of withdrawal complications from tremors, Delirium Tremens, or seizures.

Family Psychiatric/Substance Use History: This section contains any family history of psychiatric illness, substance use illnesses, and family suicides. You may choose to use a genogram to depict this information. Be sure to include a reader’s key to your genogram or write up in narrative form.

Social History: This section may be lengthy if completing an evaluation for psychotherapy or shorter if completing an evaluation for psychopharmacology. However, at a minimum, please include:Case Study

Where patient was born, who raised the patient

Number of brothers/sisters (what order is the patient within siblings)

Who the patient currently lives with in a home? Are they single, married, divorced, widowed? How many children?

Educational Level

Hobbies:Case Study

Work History: currently working/profession, disabled, unemployed, retired?

Legal history: past hx, any current issues?

Trauma history: Any childhood or adult history of trauma?

Violence Hx: Concern or issues about safety (personal, home, community, sexual (current & historical)

Medical History: This section contains any illnesses, surgeries, include any hx of seizures, head injuries.

Current Medications: Include dosage, frequency, length of time used, and reason for use. Also include OTC or homeopathic products.

Allergies: Include medication, food, and environmental allergies separately. Provide a description of what the allergy is (e.g., angioedema, anaphylaxis). This will help determine a true reaction vs. intolerance.

Reproductive Hx: Menstrual history (date of LMP), Pregnant (yes or no), Nursing/lactating (yes or no), contraceptive use (method used), types of intercourse: oral, anal, vaginal, other, any sexual concerns

ROS: Cover all body systems that may help you include or rule out a differential diagnosis. Please note: THIS IS DIFFERENT from a physical examination!Case Study

You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.

Example of Complete ROS:

GENERAL: No weight loss, fever, chills, weakness, or fatigue.Case Study

HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.

SKIN: No rash or itching.

CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.

RESPIRATORY: No shortness of breath, cough, or sputum.

GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.

GENITOURINARY: Burning on urination, urgency, hesitancy, odor, odd colorCase Study

NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness.

HEMATOLOGIC: No anemia, bleeding, or bruising.Case Study

LYMPHATICS: No enlarged nodes. No history of splenectomy.

ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.

Physical exam (If applicable and if you have opportunity to perform—document if exam is completed by PCP): From head to toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head-to-toe format i.e., General: Head: EENT: etc.

Diagnostic results: Include any labs, X-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines).

A ssessment

Mental Status Examination: For the purposes of your courses, this section must be presented in paragraph form and not use of a checklist! This section you will describe the patient’s appearance, attitude, behavior, mood and affect, speech, thought processes, thought content, perceptions (hallucinations, pseudohallucinations, illusions, etc.)., cognition, insight, judgment, and SI/HI. See an example below. You will modify to include the specifics for your patient on the above elements—DO NOT just copy the example. You may use a preceptor’s way of organizing the information if the MSE is in paragraph form.Case Study

He is an 8-year-old African American male who looks his stated age. He is cooperative with examiner. He is neatly groomed and clean, dressed appropriately. There is no evidence of any abnormal motor activity. His speech is clear, coherent, normal in volume and tone. His thought process is goal directed and logical. There is no evidence of looseness of association or flight of ideas. His mood is euthymic, and his affect appropriate to his mood. He was smiling at times in an appropriate manner. He denies any auditory or visual hallucinations. There is no evidence of any delusional thinking. He denies any current suicidal or homicidal ideation. Cognitively, he is alert and oriented. His recent and remote memory is intact. His concentration is good. His insight is good.Case Study

Differential Diagnoses: You must have at least three differentials with supporting evidence. Explain what rules each differential in or out and justify your primary diagnostic impression selection. You will use supporting evidence from the literature to support your rationale. Include pertinent positives and pertinent negatives for the specific patient case.Case Study

Also included in this section is the reflection. Reflect on this case and discuss whether or not you agree with your preceptor’s assessment and diagnostic impression of the patient and why or why not. What did you learn from this case? What would you do differently?Case Study

Also include in your reflection a discussion related to legal/ethical considerations ( demonstrating 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.).

References (move to begin on next page)

You are required to include at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines which relate to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting.

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Assignment: Assessing and Diagnosing Patients with Mood Disorders

Case Study

Photo Credit:

Accurately diagnosing depressive disorders can be challenging given their periodic and, at times, cyclic nature. Some of these disorders occur in response to stressors and, depending on the cultural history of the client, may affect their decision to seek treatment. Bipolar disorders can also be difficult to properly diagnose. While clients with a bipolar or related disorder will likely have to contend with the disorder indefinitely, many find that the use of medication and evidence-based treatments have favorable outcomes.Case Study

To Prepare:

· Review this week’s Learning Resources. Consider the insights they provide about assessing and diagnosing mood disorders.Case Study

· Download the Comprehensive Psychiatric Evaluation Template, which you will use to complete this Assignment. Also review the Comprehensive Psychiatric Evaluation Exemplar to see an example of a completed evaluation document. Case Study

· By Day 1 of this week, select a specific video case study to use for this Assignment from the Video Case Selections choices in the Learning Resources. View your assigned video case and review the additional data for the case in the “Case History Reports” document, keeping the requirements of the evaluation template in mind.Case Study

· Consider what history would be necessary to collect from this patient.Case Study

· Consider what interview questions you would need to ask this patient.Case Study

· Identify at least three possible differential diagnoses for the patient.

Case Study

By Day 7 of Week 3

Use this video I chose video training title 8. this is the link: Training Title 8 – Alexander Street, a ProQuest Company (openathens.net)

Complete and submit your Comprehensive Psychiatric Evaluation, including your differential diagnosis and critical-thinking process to formulate a primary diagnosis. Incorporate the following into your responses in the template:

· Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life? Case Study

· Objective: What observations did you make during the psychiatric assessment?  Case Study

· Assessment: Discuss the patient’s mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses with supporting evidence, listed in order from highest priority to lowest priority. Compare the DSM-5-TR diagnostic criteria for each differential diagnosis and explain what DSM-5 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.

· Reflection notes: What would you do differently with this client if you could conduct the session over? Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), 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.).

Case Study

CASE STUDY essay paper

CASE STUDY

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Human Needs Theory Interactive Case Study (Links to an external site.)Complete the Human Needs Theory Interactive Case Study following the readings and presentation for this week. Associate what you have learned about the theories to this case study, and then see the instructions below to complete a journal entry about your experience.During weeks 2 & 4, you will complete interactive case studies and be asked to associate what you have learned about theory in comparison to the case study and reflect on it.Each time you have completed a case study, submit your reflection. Each reflection should include the following:CASE STUDY

  • A comparison of what you have learned from the case study to related theories you have studied. Make sure to cite these theories in APA format.CASE STUDY
  • A comparison of the case study to your nursing practice, giving one or two examples from your nursing experience in which you might have applied a particular theory covered.CASE STUDY

Your reflection should be a minimum of five to six paragraphs.

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COURSE NURS 500 Theoretical Foundations of Nursing Practice

CASE STUDY

Case Study essay paper

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2

Case StudyCase Study

Lab Assignment

Name:_____________________

Date: _____________________

Course: OTA 104/105: Activity Analysis

Course objective(s):

UNIT SEVEN: Analyzing Human Motion in Daily Activity

Upon successful completion of this unit on written and practical examination, the student will:

Analyze various case examples by:Case Study

a. Identifying physical performance impairments during an occupation.

b. Selecting appropriate tests to assess the indentified physical performance deficits.

c. Determining and justifying in written form which model of practice/frame of reference would best guide the treatment of the identified impairments.

d. Implementing the selected frame of reference/model of practice in correcting, or compensating, for the identified impairments.Case Study

e. Role-playing a treatment session based on student analysis

Curriculum thread(s) addressed:

· Occupation Centered PracticeCase Study

· Role Acquisition

Assignment Objectives:

· The student will identify and demonstrate (as applicable) role and participation in the Occupational Therapy process (referral, screening, evaluation, treatment planning, intervention, reevaluation and discharge planning)

· The student will determine and select the model of practice/frame of reference that would best guide the treatment of the identified impairments.Case Study

· The student will demonstrate proficiency in applying OT treatment techniques and practices to a case study that will be assigned to them.

· The student will create a problem list, list of strengths, long-term goals, and short-term goals.

· The student will demonstrate treatment session which will be described in an intervention note.Case Study

· After the treatment session, the student will identify opportunities to recommend to the occupational therapist the need for referring client for reevaluation, discharge planning and additional evaluation for other services and/or professional(s).

Procedure:Case Study

· The student will be assigned a case study with an array of physical dysfunctions.

· Student will complete an analysis based on a structure and guideline that requires information in regards to: Problems, strengths of the client, long-term and short-term goals for treatment.

· Student will develop two treatment sessions applying techniques, strategies and practices

· Student will demonstrate by role play, one treatment session.

· Student will write an intervention/treatment note accordingly.

Written assignment:

Poor (1)

Fair (2 )

Good (3)

Excellent (4)

Score

Determine and select model of practice/frame of reference to best guide the treatment of the identified impairments.

Unable to determine appropriate Application of model of practice/frame of reference

Additional questions arise. Difficult to follow, yet selected practice/frame of reference is present.

Application of model of practice/frame of reference requires additional clarification

Application of model of practice/frame of reference is best suited

Use of proper OTPF terminology and grammar

Use of inaccurate terminology or grammar on more than 8 occasions.Case Study

Use of inaccurate terminology or grammar on no more than 6 occasions.

Correct use; with use of inaccurate terminology or grammar on no more than 4 occasions.

Correct use; with use of inaccurate terminology or grammar on no more than 2 occasions.

Summary of primary and secondary medical diagnoses: signs, symptoms, prognosis, prevalence

Did not identify. Clarification neededCase Study

Missing 50% of data

Missing 25% of data

All relevant information provided

Developed a prioritized OT Problem list.

Explained justification of prioritization using the OTPF.

Not addressed or information not relevant.

Only two problems are OT relevant and student requires additional clarification about how practice framework is utilized to prioritize problem list.

Most problems are OT related and can be addressed by therapist. Most problems prioritized and justified with fair use of practice framework.

Problem list is accurate and prioritized considering patient specific diagnosis, needs, and wants. Utilized and explained clearly application of practice framework to problem list.

Identified all problems of the patient accurately

Did not identify problems accurately on 5-6 occasions

Did not identify problems accurately on 3-4 occasions

Identified all problems, but did not identify problems accurately on 1-2 occasions

Identified all problems accurately

Identified accurately and correctly all strengths and opportunities of the patient in the case study

Did not identify accurately and correctly all strengths and opportunities of the patient in the case study on 5-6 occasions

Did not identify accurately and correctly all strengths and opportunities of the patient in the case study on 3-4 occasionsCase Study

Identified accurately and correctly mostly, but failed to identify accurately and correctly on 1-2 occasions

Identified accurately and correctly all strengths and opportunities of the patient in the case study

Completed all long term goals accurately and correctly meeting all the criteria utilizing FEAST or other documented methodCase Study

Did not complete long term goals accurately and correctly meeting all criteria on 5-6 occasions

Did not complete long term goals accurately and correctly meeting all criteria on 3-4 occasions

Completed long term goals accurately and correctly meeting most criteria, but missing on 1-2 occasions

Completed all long term goals accurately and correctly meeting all the criteria

Completed all short term goals as applicable

Did not complete 5-6 short term goals

Did not complete 3-4 short term goals

Good, but missed the completion of 1-2 short term goals

Completed all short term goals as applicable

Methods/Interventions

Listed methods used to treat patient in a comprehensive list to be used as treatment plan guide. Indicate FOR (s) for treatment session.

Information provided is vague.Case Study

Methodology is not comprehensive and lacking information.

Good, but additional clarification needed.

Comprehensive list of methods that will be used in intervention. Sound, research based methodology is evident FOR (s) is indicated.

Rationale/Justification

Describes the rationale behind above methods and gives reason why this will work (justification)

Unacceptableperformance and clinical reasoning

Rationale is missing or not sound on several methods

Good, but rationale is incomplete or not sound on some methods

Sound rationale given for each method. Comprehensive.

Created and developed two treatment sessions utilizing time management skills and progression in the treatment continuum

Did not create and develop treatment sessions accurately and correctly

Creation and development treatment of sessions require additional work. Uses clinical reasoning skills for 50% of session

Good overall. Additional clarification required. Most ideas are good and uses clinical reasoning skills for 75% of session

Created and developed two treatment sessions accurately and correctly, meeting the criteria

Treatment session:

Description of main medical diagnosis, and any precautions.

Brief description of patient’s status and goals.Case Study

Too long or too short of expected length of time

Part of the treatment session is appropriate and addresses goals.

Most of treatment session is appropriate & addresses goals.

Medical and diagnoses information covered. Important precautions mentioned. Brief discussion of patient’s status and goals-

Uses and prepares equipment in the lab.

Last minute preparation with materials.

Creativity shown.

Creativity, flexibility. Demonstrates how activity can be graded.

Overview of treatments selected and why they are appropriate for this patient is indicated.

Address Q & A.

Unable to answer questions from instructor/ students related to rational or activity analysis or interventions.

Nervous, but attempts to answer questions at the end of treatment session.

Answers questions easily and somewhat accuratel y at the end of treatment session .

Student is able to explain and answer all questions at the end of treatment session. Shows how activities can be graded up or down. Rational is complete

Shows creativity. At the end of the treatment session, identifies opportunity to recommend to the occupational therapist the need for referring client for reevaluation, discharge planning and additional evaluation for other services and/or professional (s).

Written activity analysis for each activity.

Vague, not well elaborated, does not address value or meaning of activity. Explanation will not contribute to analysis.

Many questions arise. Data provided is acceptable, but more effort is required.

Data provided that may assist in identifying value of activity for use in treatment requires minimal additional clarification.Case Study

Well discussed, provides meaningful relevant data that may assist in identifying value of activity for use in treatment

Shows progression from adjunctive to purposeful as appropriate.

Rationale and explanation of interventions.Case Study

Unacceptable. More creativity and justification required.

Many questions arise. Rationale and explanation of interventions requires additional focus and concentration

Progression from adjunctive to purposeful requires additional thought process.

Rationale and explanation of interventions require additional work but can be followed. Some questions arise.

Progression from adjunctive to purposeful as appropriate.

Rationale and explanation of interventions is clearly identified.

Shows priority as related to discharge plans as appropriate.

Vague and not well elaborated.

Priority as related to discharge plans is not as evident. Many questions arise

Priority as related to discharge plans requires additional clarification

Priority as related to discharge plans as appropriate.

After treatment session, identification of

opportunity to

recommend to the occupational therapist the need for referring client for reevaluation and additional evaluation for other services and/or professional (s).

Unacceptable. Evidence of knowledge and understanding is not apparent

Identification of

opportunity to

recommend to the occupational therapist the need for referring client for reevaluation and additional evaluation for other services and/or professional (s) is articulated, however, many questions arise

Identification of

opportunity to

recommend to the occupational therapist the need for referring client for reevaluation and additional evaluation for other services and/or professional (s) is articulated., however, knowledge and understanding is not as apparent. Minimal clarification to increase knowledge and understanding required.

Identification of

opportunity to

recommend to the occupational therapist the need for referring client for reevaluation and additional evaluation for other services and/or professional (s) clearly articulated. Knowledge and understanding is evident.

Evidence based treatment: AJOT or other researched based articles are used to support one intervention.

Copies of article included with paper.

No evidence of article or

more than 25% of the information is not accurately transcribed.

Selection of articles are not highly relevant to case study/or is/are insufficient.

Another article is recommended

Selected article supports specified intervention, but rationale requires additional clarification

Selected article addresses specified intervention with supporting rationale provided

Treatment Note:

Completed all sections of the intervention/treatment note utilizing all the necessary criteria

Unacceptable contribution. Requires remediation in note writing.

Additional clarification is required. Moderate corrections required

Minimal corrections required, however, able to follow

Completed all sections of the intervention/treatment note

Subjective

Objective

Assessment

Plan

Comment:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Score:

Paper: Your score was _____________

Treatment session: Your score was _____________

Treatment note: Your score was _____________

The total score to accumulate is “56”. Your score was _____________ with a

percentage of _______________

ACOTE Standards for an Accredited Educational Program for the Occupational Therapy Assistant:

(B.2.11. , B.3.2., B.4.1., B.4.4., B.4.96., B.5.4.92., & B.5.84.10)

Revised 12/08/15 JM; revised 04/2029/2016 2020 JM

Case Study essay paper

Case Study

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Case Study about chapter 19 SEAN: Left Above Knee Amuptation, Stage II Sacral Decubitus Ulcer in skilled nursing.Case Study

Please see the assignment objective below and the complete chapter is below in the document is CHAPTER 19Case Study

Need to be a Word Document with APA references. Do no matter how many word or pages, all I need is the assignment objectives, procedure,Analyze various case examples, by about Chapter 19 is a client named SEAN.Case Study

See document Attach! Case Study

Case Study essay paper

Case Study

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Case Study about chapter 19 SEAN: Left Above Knee Amuptation, Stage II Sacral Decubitus Ulcer in skilled nursing.Case Study

please see the assignment objective below and the complete chapter is below in the document is CHAPTER 19Case Study

Need to be a Word Document with APA references.Case Study Do no matter how many word or pages, all I need is the assignment objectives about Chapter 19 is a client named SEAN.Case Study

Case Study essay paper

Case Study

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EF is a 74-year-old African American male who is seeing his PCP because he noticed when he woke up that his “heart was not beating right; it feels like it is going to slow.” He denies chest pain, SOB, N/V. He notes feeling dizzy earlier in the day. Six weeks earlier his PCP started him on Diltiazem CD to further lower his BP to goal. His Metoprolol was lowered at that time as well from 75 mg to 50 mg BID. His PCP recommends he be admitted to the hospital. Case Study

Upon presentation to the hospital:

 

PMH:

HTN x 7 years

Type 2 DM

CAD s/p angioplasty 2 years ago

MI 3 years ago

EF = 60%

PVD s/p left femoral to posterior bypass

Hx of A Fib x 4 years

Case Study

Medications:

Digoxin 0.25mg once daily

KCl 40mEq once daily

Vitamin C 500mg once daily

Diltiazem CD 180mg once daily Case Study

ASA EC 325mg once daily

Vitamin E 400 IU once daily

Metoprolol tartrate 50mg twice daily

Warfarin 5mg once daily

Ibuprofen 200mg – 2 tabs prn headache

Lisinopril 20mg once daily

Famotidine 20mg once daily at bedtime

MVI once daily Case Study

Imdur 30mg once daily

Lantus 26U once daily at bedtime

Ca++/Vit D 500mg/200 IU twice daily

HCTZ 12.5mg once daily

Humalog 8U three times daily with meals

 

Vitals:

BP: 110/50

HR: 38 bpm

RR: 14/min Case Study

Rest of physical exam unremarkable

 

Labs:

Gluc 102

Na 135

K 6.9  Case Study

BUN 35

Scr 1.9

WBC 5,800/mm3

Hct 35%

INR 2.3

Dig 2.78

 

Write a 2- to 3-page paper that addresses the following:

  • Explain how the factor [genetics, gender, ethnicity, age, or behavior factors} you selected might influence the pharmacokinetic and pharmacodynamic processes in the patient from the case study above.
  • Describe how changes in the processes might impact the patient’s recommended drug therapy. Be specific and provide examples.
  • Explain how you might improve the patient’s drug therapy plan and explain why you would make these recommended improvements.

 

Case Study