Description
In this assignment, you will review the Bipolar Interactive Case Study patient scenario and analyze the data to determine the health status of the patient.
Select the Patient Subjective Information tab. Within this tab, you will be able to watch a video to gain more insight regarding the patient as well as view important patient details.
For this assignment, you will
Review the Case Study.
Review the Comprehensive Case Study Content Exemplar to understand what is needed within your paper.
Use the Comprehensive Case Study Paper Template to write the assignment in the proper format.
Follow the requirements on the rubric and within the Content Exemplar.
Interactive Comprehensive Case Studies should be 3- to 5-pages in length, excluding the title and reference pages.
Interactive case studies should include a minimum of three evidence-based practice guidelines or articles.
All papers should conform to the most recent APA standards.
Your case study write up should include specific reference to relevant guidelines and other clinical information. The national guidelines should also be considered within treatment plans.
When you have completed viewing the patient information, download the Comprehensive Case Study Paper Template (Word) from the assignment page in Moodle. Use this document to complete the assignment and then submit it to the assignment drop box. Additionally, there is an Exemplar document for review to help guide your case study write up.
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Bipolar Case Study Transcript
Chief Complaint:Mrs. Sylvia Contesta is a 62-year-old Hispanic female with complaint of “sometimes I hear
people talking about me and they stare.” Patient is accompanied by her oldest daughter to the visit.
History of Present Illness:
Onset:For the past 2 months, patient has been up all night cleaning because she cannot sleep.
Location:Headaches on occasion.
Duration:Past 2 months.
Characteristics: Daughter reports that her mother is constantly cleaning out and reorganizing drawers and
closets and is “throwing out things—stating she no longer needs them.” The daughter notes that most things are
not trash or unwanted so she finds this odd behavior.
Patient reports that she is “not tired” even without sleep and “has a lot to do to welcome festivities for her
granddaughter’s new baby arrival next year.” The daughter reports that none of the grandchildren are “having
babies.”
The daughter is worried about her mother’s drastic change of behavior and attitude, which is becoming more
tearful, irritable, and angry when they try to stop her from all the cleaning and organizing.
Aggravating: Increased symptoms with decreased sleeping.
Relieving: Rest, sleep, can be distracted with visits from family.
Temporal: Worse on weekends when she has less visitors.
Severity: I just don’t sleep sometimes but my family is bothered by my cleaning. I just want everything neat and
completed for upcoming events.
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Patient Comprehensive Assessment Information
Patient Histories
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Past Medical History
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Coronary Artery Disease X 3 years ago
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Hypertension – X 8 years
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Osteoarthritis X 2 years ago
• Diabetes X 6 years ago
Surgical
o Cholecystectomy, age 49
Ongoing
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Coronary Artery Disease
o
Hypertension
o
Osteoarthritis
•
o Diabetes
Psychiatric History
•
Inpatient and Outpatient Psychiatric/Mental Health Care: No previous
psychiatric inpatient care. Has a previous history of taking an SSRI for a short time
several years ago for anxiety and panic related to grief after wife’s passing. Denies
any suicidal ideation or past attempts.
o Past Psych Diagnosis (es): None.
o Treatments: Endorses seeing a therapist after his wife died and meeting in a grief
group at church. Treatments:
❖ Previous Medication Trials: Patient cannot recall: “I think it was something
with a Z for anxiety and depression when my wife passed. I only took it for a
few months to get through.”
❖ Previous Therapy Trials: Reports the therapist assisted him in considering
his new life plan without his wife. Group therapy assisted him with moving
on.
❖ Outcomes of previous treatment: Does not recall.
❖ Current Psychotropic Medications: None.
Developmental History
o
o
o
o
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Substance Use: Denies any use of nonprescription medication, denies use of
tobacco or ETOH.
o Trauma History: Denies any past history of trauma.
Social History
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Birth History: Unknown
Developmental Delays: Unknown
How were they managed? None identified.
If any delays, what therapies were used, and did they help? N/A
Retired but worked in the corporate world for 40 years. Is used to being very active in
the community and usually spends several hours per week helping out at the local
hospital as a greeter and volunteer. He was unable to go to volunteer work for the
last month due to feeling down. Widowed three years ago, wife passed away from
cancer. They shared 50 years of marriage and have two daughters, aged 30 and 32.
One daughter lives with her family in a house down the street from him and visits
daily. He does not drive anymore but usually visits his daughter daily after a walk
around the block. He enjoys gardening and has a rose garden in memory of his wife.
Denies history of tobacco, ETOH, or drug use.
o Spirituality: None
Family History
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o
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Father: Died age 76 (HTN)
Mother: Died age 52 (Stroke)
Brother: Died age 22 (WWII casualty)
Brother: Died age 80 (HTN, asthma, DM)
Daughter 1: alive, age 30
Daughter 2: alive age 32
o Family History of Psychiatric Mental Illness: Unknown
o Family History of Suicide: Denied
Safety
o Regularly wears seatbelt when riding as passenger.
o No weapons in the home
Medications
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Diclofenac sodium topical 1% gel, apply 4 grams QID to both knees
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Aspirin 325mg 1 tablet PO daily
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Valsartan 80 mg 1 tablet PO daily
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Lipitor 40 mg 1 tablet PO at bedtime
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Omeprazole 20 mg 1 tablet PO daily before meal
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Cyanocobalamin 1 mg 1 tablet PO daily
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Claritin 10 mg 1 tablet PO daily
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Flonase nasal spray two puffs to each nostril daily
The patient discloses additional medications only when his granddaughter leaves the room, stating,
“They think I may possibly also have a slight case of prostate cancer, so I take these.” He pulls two
pill bottles from his jacket pocket:
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Flomax 0.8 mg 1 capsule PO at bedtime
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Finasteride 5 mg 1 tablet PO daily
The patient claims he started this four weeks ago.
Allergies
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Medication: NKA
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Food: NKA
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Environmental: NKA
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Latex: NKA
Review Of Systems
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General – Reports usual health as “pretty good.” Denies fever, chills, weight changes.
Respiratory
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Denies cough, dyspnea, or wheezing.
o Denies past hx of asthma, recurrent infections
Cardiovascular – Denies chest pain, palpitations.
Neuro – Denies coordination problems, numbness, tingling. Endorses some recent weakness
and slight tremors in his hands. Denies seizures or frequent headaches. Not aware of
memory problem. No head injury
Psychiatric Review of Systems
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Mood – Denies feelings of depression, but reports feelings of panic and anxiousness
most of the day, with worsening anxiety in late evening. Anxious for the past three years,
with an increase in symptoms over the past three to six months. Affect is full ranging.
Only feels irritable when anxiety worsens; denies feeling easily tearful. Reports difficulty
getting up in the mornings when sleep has been poor
Sleep – Reports difficulty falling asleep almost every night, and some middle-night
awakening.
Interests – No loss of interest or pleasure in activities, although reports he has started to
avoid some social activities that cause him to feel anxious.
Feelings of Guilt – No feelings of hopelessness, helplessness, or hostility; denies any
feelings shame or lack of motivation. Endorses some feelings of guilt that he will need
help with care if his hands get worse from shaking.
Energy – No increased energy; reports feeling fatigued most days, especially when sleep
is poor.
Concentration – Some difficulty concentrating when worrying or with increased anxiety
Appetite – No increased or decreased appetite.
Psychosis – No delusions, hallucinations, feelings of persecution, hearing sounds that
seem to be voices or preoccupation with religion.
Self-harm/Suicide Risk- No self-inflicted injuries; no frequent thoughts of death, lack of
desire to continue living, or suicidal tendencies. No homicidal thoughts.
•
Precipitating Factors- No interpersonal relationship problems, family problems, or legal
problems. Concerned about recent diagnosis and health concerns. Concerned family will
need to take care of him more and will lose independence.
General Appearance
Mr. Bert Colton is an 89-y/o Caucasian male who articulates clearly but softly, ambulates slowly
without difficulty, and is in no acute distress. General appearance is same as stated age, with a
normal level of personal hygiene, no inappropriate clothing, no bizarre personal appearance.
Remainder of physical exam deferred during psychiatric mental health assessment.
Vital Signs – Ht 59in, Wt 172lbs, BP 138/82, Temp 98.6, HR 86, RR 78 irregular
Mental Status Exam
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General – A&Ox4, appearance, behavior, and speech appropriate. Thoughts coherent.
Remote and recent memories intact.
Behavior – Wrings hands when he speaks; no hypervigilance, heightened startle reflex,
abnormal mannerisms, or uncommunicative/disinterested/hostile/inattentive attitude.
Movement- No tremor or tics; normal gait and stance; no involuntary movements.
Speech – No refusal to speak or loosening of association/word salad; not slowed, rapid, or
difficult; normal rhythm of speech, speech tone, and speech volume.
Mood – Not dysthymic or depressed; appears moderately anxious, not dysphoric, euphoric,
angry, elevated, or expansive.
Affect – Full ranging; not blunted or constricted.
Language – No language abnormalities; speech fluent; no dysphonia; no stuttering; language
fluent and intact for naming; normal sentence structure
Cognition – Patient oriented x4, no disorientation, short-term memory impairment, or
reduced abstraction ability; diminished cognitive functioning only when anxiety is intense
Thought Process – No deficiency on evaluation of connectedness; organized.
Thought Content – No thought content impairment; no suicidal ideation, homicidal
ideations, paranoid ideations, poverty of thought, thought insertions, obsessions, irrational
fears, delusions, or hallucinations.
Insight & Judgement – No impaired insight, impaired judgment, or poor problem solving.
Lab Values – No recent labs on file.
Comprehensive Case Study Rubric
Comprehensive Case Study Rubric – 100 Points
Criteria
Exemplary
Exceeds
Expectations
Advanced
Meets
Expectations
Intermediate
Needs
Improvement
Novice
Inadequate
Total
Points
Differential
Diagnoses
All required
differential
diagnoses are
included (including
worst case) and fully
supported by
findings.
Most required
differential
diagnoses are
included (including
worst case); one is
not supported by
findings.
Some required
differential
diagnoses are
included (not
including worst
case); two are not
fully supported by
findings.
Few required
differential
diagnoses are
included; more than
two are not fully
supported by
findings.
10
Rationale for all
differential
diagnoses provided.
Rationale for most
differential
diagnoses provided.
10 points
8 points
Rationale for some
differential
diagnoses provided.
Rationale provided
for few differential
diagnoses.
6 points
7 points
Rationale
Rationale provided
for all answers and
decisions made
regarding patient
care. Rationale is
based on current
evidence, with 0
errors.
Rationale provided
for most answers
and decisions made
regarding patient
care. Rationale is
based on current
evidence, with 1–3
minor errors or 1
major error.
Rationale provided
for some answers
and decisions made
regarding patient
care. Rationale is
based on current
evidence, with 4–6
minor errors or 2
major errors.
Rationale provided
for few answers and
decisions made
regarding patient
care. Rationale is
based on current
evidence, with 6+
minor errors or 2+
major errors.
17 points
15 points
13 points
Plan missing 1 of
the identified
components:
Plan missing 2 of
the identified
components:
Plan missing >3 of
the identified
components and/or
has safety
concerns.
20
20 points
Plan
Comprehensive
plan includes all
components:
Diagnostic
testing
Pharmacologic
intervention
Nonpharmacologic
intervention
Referrals
Patient
education
Follow-up
40 points
Diagnostic
testing
Pharmacologic
intervention
Nonpharmacologic
intervention
Referrals
Patient
education
Follow-up
35 points
Diagnostic
testing
Pharmacologic
intervention
Nonpharmacologic
intervention
Referrals
Patient
education
Follow-up
Diagnostic
testing
Pharmacologic
intervention
Nonpharmacologic
intervention
Referrals
Patient
education
Follow-up
31 points
27 points
40
Approach to
Patient Care
Approach to patient
care is organized,
logical,
patientcentered,
and costeffective,
with 0 errors.
Approach to patient
care is organized,
logical,
patientcentered,
and costeffective,
with 1–3 minor
errors or 1 major
error.
Approach to patient
care is organized,
logical,
patientcentered,
and costeffective,
with 4–6 minor
errors or 2 major
errors.
17 points
15 points
Logical and
systematic
organization of data.
Logical and
systematic
organization of data.
Minor errors in
organization of data.
Disorganized flow of
data.
Correct terminology,
spelling, and
grammar.
Terminology,
spelling or grammar
errors (1–3).
Terminology,
spelling, or grammar
errors (4–6).
Terminology,
spelling, or grammar
errors (>6).
7 points
6 points
10 points
8 points
20 points
Approach to patient
care is organized,
logical,
patientcentered,
and costeffective,
with 6+ minor errors
or 2+ major errors.
20
13 points
Documentation
Total Points
10
100
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