Identifying Information: : LM is a 67 year old Caucasian woman accompanied by her male partner. LM has a business degree and worked as an office manager.
Setting:
First visit with PMHNP for diagnostic evaluation at the Outpatient Community Mental Health Clinic
Chief Complaint:
The client’s partner reports that LM has had increasing difficulty with memory and decision making, but what is even more troubling is an increasing difficulty with “know how” to complete simple tasks. He states, “she would call me at work because she couldn’t remember how to start the car.” LM states, “ I don’t know why you are making such a big deal out of this…. I just want to go back to the way we were. Can we go home?”
History of Present Illness:
LM had worked in a Doctor’s office up until 1 year ago when she left to work as a cashier at a local Target. LM’s partner reports that she had quit the cashier job when she began having a great deal of frustration over running the cash register. In addition she was reported as having had a car accident in which she was entering the intersection in front of an oncoming vehicle and was hit broad- side. When asked what had happened following the accident, LM was unable to say. LM apparently sustained no injuries but she did decide to quit her job at Target soon after this event. Over the next few months LM was reportedly irritable and angry much of the time which represented a change from her usually kind and calm personality. She, on one occasion, had called the police when she couldn’t reach her partner and was convinced that the locks had been changed on her house because she was not able to get in. The partner relates that he was beginning to fear for her safety after she left the burner on under an empty pan causing a fire on top of the stove. During much of the intake LM sits with her head down, affect is angry at times and at other times sad. LM reportedly used to drink but has not had a drink in over a year that he knows of.
Marital History: LM was married for 22 years and has two daughters from that marriage. She has been with her current partner for 10 years. There is apparently conflict between the partners and LM’s partner.
Past Psychiatric History:LM has no prior psychiatric history per client’s partner as well as client.
Medical History:
History of hypertension, well controlled with Norvasc. Examination following the automobile accident revealed no injury. She has no other health issues or concerns and is considered to be in overall good health.
Surgical History:
None.
Family Medical History: LM reports both of her parents are deceased.
Family Psychiatric History:
There is little known about LM’s family’s psychiatric history. LM’s partner reported that LM had told him that her mother had died in a nursing home when she was still fairly young.
Medical Review of Systems:
General: Denies any weight gain or loss
Integumentary: Denies rashes, sores, changes in skin or moles.
Endocrine: Denies hx of goiter. Denies polyuria, polydipsia. c/o fatigue
Hematologic: Denies easy bruising or bleeding, No past infusions.
Musculoskeletal: c/o diffuse chronic knee pain
Neurological: denies fainting, blackouts, seizures, tremors, involuntary
movements, stroke
Breast: Denies lumps, pain, discharge.
Neck: Denies lumps, swollen glands, goiter, pain or stiffness
Mouth/throat: Denies problems with teeth or gums, sores, dry mouth, hoarseness
Nose/sinuses: Denies frequent colds, nasal stuffiness, discharge, itching, nosebleeds
Ears: Denies hearing loss, tinnitus, vertigo, earaches, infections
Eyes: Denies vision problems, glaucoma, cataracts, eye surgery
Head: Complains of dizziness and occasional lightheadedness
Respiratory: Denies shortness of breath, wheezing, cough, sputum production, hemoptysis, asthma
Cardiac: Denies chest pains, palpitations, murmurs, abnormal EKG, edema. History of hypertension controlled withmedication.
GI: Denies hx of GERD, abdominal pain, N/V/D, constipation, black tarry stools, gallbladder trouble, jaundice, hemorrhoids
Neurologic: Denies numbness, paresthesia, weakness
GU: Denies frequency, urgency, burning, bloody urine, incontinence, Uses IUD. Periods are “heavier”
Vaccine status: Current on all including flu vaccine.
Vital Signs:Ht: 5’4”, Wt: 130lbs, BP 120/78, Pulse, 82, Resp 16, Temp 98.2. Waist circumference: 32 inches
MSE/Observations: LM is a 67yo Caucasian female appears her stated age. She is well dressed and neat in appearance. She sits erect but her head is held down and she clasping and unclasping her hands. She is alert and oriented to person, place, and situation but not to timeAttitude: pleasant, cooperative, and friendly. Motor: Ambulates with even gait, steady. Speech: clear, normal, rate, volume, tone, and amount. Articulate and Spontaneous however she hesitates when asked about recent events including what she had eaten for “dinner last night” Mood:LM partner reports she has been sad lately. Affect: blunted. Thought process: CoherentThought Content:Can’t we just forget about all of this and just go home.” Denies auditory visual, olfactory, and tactile hallucinations. Some controlled worry about how “she has been worrying everyone and she doesn’t know why”. Denies hx of mania or hypomania, denies obsessions or compulsions. Denies history of panic attacks. Denies ETOH or drugs beyond a “glass of wine a night”Insight/ Judgment: fair. Intellect: average. Calculated Memory:Objects 1/3. Recent and remote: recent memory is poor.
Questions:
Case conceptualization (20 points)
The case study for this module is on a client with cognitive disorders. In addition to the DSM5 there is an article, Differentiating the Three D’s: Delirium, Dementia, and Depression which I think you will find helpful in the differential diagnosis.
Use your DSM5 texts, the 3 D’s article and other relevant sources to develop your clinical impression.
Refer to the rubric for the grading criterion.
1. Create a concept map, table, or decision tree to help you identify all relevant psychiatric and medical conditions you would consider for this individual. Include the DSM5 criteria for psychiatric diagnoses.
2. From the above, create a prioritized list of your top 3 differential psychiatric diagnoses, starting with the primary working diagnosis (your answer), include the ICD 10 diagnostic code for each diagnosis. Explain your thinking process on what factors you considered that led you to select your primary diagnosis, and other possible diagnoses.
3. List 2 most pertinent differential medical conditions you would consider for this individual. Provide a brief list of symptoms that support your medical differentials.
For questions 1-3, provide text/reference, page number (in APA style) where you found the information to support your thinking. Use your own words, limit any direct quotes to no more than 1-2 phrases.
