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WK#7: PRAC 6675 COMPLEX CASE STUDY PRESENTATION
Silibaziso Masebe, M.S in Nursing (MSN)-BSN-PMHNP College of Nursing PMHNP, Walden University
PRAC 6665: Psychiatric Mental Health Nurse Practitioner Across the Lifespan 1
Elizabeth Ann Connole-Pond MSN, APRN PMHNP-BC
July 12, 2023
Subjective:
CC (chief complaint): “I struggle to sleep at night.”
HPI: S.B. is a 15-year-old male with ADHD(predominantly hyperactive-impulsive type), DMDD, MDD without psychotic features, PTSD, and adjustment disorder with anxiety symptoms related to moving to a new school and town. He lives with hismom, younger brother, and stepdad. He was seen on 6/23/23 for a medication and mental status examination follow-up appointment with his mother. He reported, “I struggle to sleep at night.” He said he does not want to disturb his parents at night to get the pm Clonidine 0.1mg. He reported his mood as “irritable” because the kids at school picked on him. He is on Vyvanse 10mg in the morning to improve focusing and concentration, Propranolol 10mg, one tablet as needed for situational anxiety, Lamictal 25mg, three tablets(75mg) once a day mood stabilizer for DMDD, and Clonidine 0.1mg tablet 1-2tirnes as needed foranxiety-related insomnia. He reported that he had just taken the MCAS exam and was required to complete his assignments. Hesaid his grades were good. He reported that his focus has improved from taking Vyvanse every day. He reported his appetite as”fair,” and his mother denied any issues. He said he vaped nicotine three weeks before his appointment, did not enjoy it, and would never do it again. He reported that he is not proud of it. He said that Lamictal is “sort of helping me.” He was educated on the effects of nicotine vaping, and he verbalized understanding. He was applauded for not vaping again since three weeks ago.He reported that he is looking for a summer job, and his mother will help him with the application process. He reported thathe will save his first paycheck. His mother said she attended his IEP meeting, and they are planning to move him to a different house. She reported
that he was caught vaping nicotine in the school bathroom. She stated he had an altercation with
another student that was bullying him. She said the investigation revealed that the other student had been bullying S.B., and theother student was removed from the class as discipline. She was advised to leave one Clonidine tab for the patient at night in case he needs it. The patient was educated on the side effects of nicotine, and he verbalized understanding. He reported his depression level at 2/10 and anxiety level at 3/10. He and his mother endorsed medication compliance. He was alert and oriented to person, place, time, and situation. His speech was coherent and spontaneous and had normal rate, volume, andarticulation. He denied suicidal ideations/Homicidal ideations or intentions or thoughts or plans, Self-injurious ideations orplans or intentions, and auditory/visual hallucinations. No delusions, bizarre behaviors, or other indicators of a psychotic process were noted. His PCL-5 was 10/33(did not meet the criteria for PTSD), PHQ-9 was 4/27(minimal depression), andGAD-7 was 4/21(minimal anxiety). Plan: No medication changes were made. He and his mom were encouraged to continuefollowing up with his PCP and therapy sessions to learn positive coping skills to manage psychiatric diagnoses. He waseducated on diet and exercise for weight management, stress management, and a healthy sleep schedule. His follow-up appointment is in 4 weeks or sooner if needed. Risks and benefits were discussed with the patient, and he verbalized understanding. He was advised to call (508)872-3332, 988, or 911 or go to the nearest emergency room when he feels unsafe.
Past Psychiatric History:
ï General: He was referred by his pediatrician for a psychiatric evaluation.
ï Caregivers: He lives with his mom and stepdad.
ï Hospitalizations: The patient and his mom denied any psychiatric or medical hospitalization.
ï Medication Trials: The patient his mom denied any medication trials
ï Psychotherapy: The patient and his mother mentioned that he has a therapist.
ï Previous Psychiatric Diagnosis: No previous psychiatric history was mentioned by the patient and his mother.
Substance Current Use: Denied current use. But stated he vaped nicotine three weeks before his appointment date.
Family Psychiatric/Substance Use History: His mom denied.
Psychiatric Review of Systems(PROS):
ï Depression: He reported insomnia and irritability.
ï Anxiety Symptoms: He reported irritability.
ï Panic episodes: The patient denied.
ï PTSD/Trauma: He has a history of trauma but denies current symptoms of PTSD.
ï Mood: The patient reported his mood as “irritable.”
ï OCD: He denied symptoms.
ï Mania: The patient reported irritability. He and his mom said that he vaped nicotine in the bathroom at school and got into an altercation with a peer due to being bullied.
ï Psychosis: He denied auditory/visual hallucinations. No delusions, bizarre behaviors, or other indicators of a psychotic process were noted.
ï Substance Use: Denied current use. But stated he vaped nicotine three weeks before his appointment date.
ï Appetite: He reported his appetite as “fair,” and his mother denied any issues.
ï Sleep: He reported, “I struggle to sleep at night.” Denies any nightmares or flashbacks since the last visit.
ï Energy: High.
ï Concentration/Focusing: He reported improved focusing from taking Vyvanse every day.
ï Motivation: High.
ï Hopelessness: Denied
ï Worthlessness/low self-esteem: Denied
Safety:
ï Suicidality/self-harm: He denied any previous, current, or passive suicide attempts, thoughts, intentions, or plans.
ï The patient denied any previous or recent self-harm thoughts or self-injurious behaviors.
ï He denied Homicidal Ideations and delusions.
ï He denied aggressive/destructive thoughts and behaviors toward himself and others.
However, his mother stated he had a conflict with another student and had a physical altercation.
ï The patient and his mother denied any legal issues.
ï He reported feeling safe at home, and his mother said no weapons or guns are in the house.
Psychosocial History: S.B. is a 15-year-old male who lives with his mom, younger brother, and stepdad. He was seen on 6/23/23 for a medication and mental status examination follow-up appointment with his mother. He reported that he is looking for a summer job, and his mother
will help him with the application process. He reported that he enjoys playing video games online with his friends. Hereported feeling safe at home, and his mother said no weapons or guns are in the house.
Medical History: None mentioned.
ï Current Medications: He is on Vyvanse 10mg in the morning to improve focusing and concentration, Propranolol 10mg, one tablet as needed for situational anxiety, Lamictal 25mg, three tablets(75mg) once a day mood stabilizer forDMDD and MDD, and Clonidine 0.1mg tablet l-2times as needed for anxiety-related insomnia.
ï Allergies: No known Allergies.
ï Reproductive Hx: He identifies as a male. He reported that he is not sexually active. His mother said that he reached all his developmental milestones.
ROS:
ï GENERAL: Denied fever, chills, weakness, and fatigue.
ï HEENT: Denied confusion, vision, or hearing changes; denied runny nose, congestion, sneezing, or sore throat. He denied head trauma.
ï SKIN: Denied rash, itching, or broken skin.
ï CARDIOVASCULAR: Denied chest pain, palpitations, or edema.
ï RESPIRATORY: Denied shortness of breath, cough, or sputum.
ï GASTROINTESTINAL: His mother reported he feigns stomach aches. Denies nausea,
vomiting, diarrhea, and bloody stools.
ï GENITOURINARY: Denied dysuria, urgency, hesitancy, odor, or odd color. He reported enuresis.
ï NEUROLOGICAL: His mother reported he feigns headaches. He denied head trauma, dizziness, syncope, numbnessor tingling in extremities, paralysis, ataxia, and seizures.
ï MUSCULOSKELETAL: Denied muscle, back, or joint pain and stiffness.
ï HEMATOLOGIC: He denied anemia, bruising, or bleeding.
ï LYMPHATICS: No swollen lymph nodes.
ï ENDOCRINOLOGIC: Denied polyuria, polydipsia, excessive sweating, cold, or heat intolerance.
Objective:
ï HEENT: His head was normocephalic. PERLA. The external auditory canal was patent.
ï Respiratory: His lung sounds were clear to all lung fields. No SOB or accessary muscles were used.
ï Cardiovascular: His heart rate and rhythm were regular. No murmurs, gallops, or rubs.
No peripheral edema was noted.
ï Skin: His skin was dry and intact.
ï Neurological: He was alert and oriented to person, place, time, and situation.
Diagnostic results:
PCL-5:10/33 does not meet the criteria for PTSD
PHQ-9: 4/27 Minimal depression.
GAD-7: 4/21 minimal anxiety.
Neuropsychological testing: Confirmed the diagnosis of ADHD.
Assessment:
Mental Status Examination: S.B. was alert and oriented to person, place, time, and situation. His speech was coherent and spontaneous and had normal rate, volume, and articulation. S.B. appeared his stated age and was calm, pleasant, andcooperative. He maintained eye contact and was engaging. He reported his mood as “irritable” and was congruent with his flat affect. His cognitive functioning and fund of knowledge were intact and age-appropriate. His thought process was linear and logical. His insight appeared normal, and his judgment appeared fair. He convincingly denied suicidal ideations/homicidalideations, intentions, thoughts, or plans. He denied self-injurious ideations, plans, or intentions and auditory/visualhallucinations. No delusions, bizarre behaviors, or other indicators of a psychotic process were noted. His PCL-5 was 10/33(didnot meet the criteria for PTSD), PHQ-9 was 4/27(minimal depression), and GAD- 7 was 4/21(minimal anxiety).
Diagnostic Impression:
1). (F43.23) Adjustment Disorder with mixed disturbance of emotions and conduct-acute: related to situational events. This is a failure to adjust to a stressful situation or major life changes such as moving, and the inability to handle issues is the main symptom. (Quero et al., 2022). The American Psychiatric Association (2022a) stated that both emotional symptoms, such (as anxiety and depression) and a disturbance of conduct are predominant for a patient to meet the DSM-5 diagnostic criteria. The patient moved to a new community and got bullied at a new
school. He reported irritability due to being bullied at school and difficulty sleeping. He reported that he vaped nicotine threeweeks before his appointment, and it was unpleasant, and he was not proud of himself. His mother stated he had an altercation with another student that was bullying him. The American Psychiatric Association (2022) stated that individuals meet theDSM-5 diagnostic criteria if their symptoms are less than six months. The genesis of emotional or behavioral symptoms of anindividual in response to an identifiable stressor should occur within three months of the stressor’s onset to meet the diagnostic criteria. According to MedlinePlus (n.d.) stated that adjustment symptoms, emotional and behavioral symptoms can betriggered by stressors like moving to a different home or a different city. The patient’s presenting symptoms meet the DSM-5 diagnostic criteria for adjustment disorder.
2). (51.01) Insomnia Disorder: According to the American Psychiatric Association (2022b) states that a patient meets theDSM-5 diagnostic criteria if they complain of difficulty sleeping at least three nights a week for at least three months. S.B. reported that he struggles to sleep at night. He said he does not want to disturb his parents at night to get the pm Clonidine 0.1mg.
Goldstone et al. (2018) stated that insomnia disorder is common in adolescents. The authors stated that insomnia can be difficulty initiating sleep, maintaining sleep, and early-morning awakening with an inability to sleep. S.B. meets the DSM-5criteria for insomnia because he said he struggles to sleep at night.
3). (F90.2) ADHD predominantly hyperactive-impulsive type- in partial remission(mild): The patient met the DSM-5 diagnostic criteria when full criteria were previously met for the past six months. However, the symptoms still cause social, academic, and occupational impairment.
(American Psychiatric Association, 2022c). S.B. meets the DSM-5 diagnostic criteria because he
had full symptoms more than six ago when he was admitted to the clinic, and he endorsed his current irritable mood andinsomnia. His mother stated he had an altercation with another student that was bullying him. He reported improved focusing from taking Vyvanse every day. Child Mind Institute. (n.d.) stated that a patient with ADHD can present with sleep issues and irritability.
Reflections: The patient would have been asked about his presenting symptoms’ onset, duration, and frequency. The patient would have been asked about the frequency and compliance of his therapy sessions. These questions would have helped thiswriter collaborate with his therapist regarding treatment options to prevent decompensation and also help with developing differential diagnoses and treatment plans.
Social Determinants ofHealth(SOD): According to the Office of Disease Prevention and Health Promotion(n.d., a), SODaffects a person’s health and quality of life. The environment in which an individual is born, lives, educated, is employed, worships, and ages are SOD. The patient moved to a new town and school, where he was bullied, triggering his symptoms.
Healthy Promotion: Healthy People 2030 for Children aims to raise the number of children with mental health issuesreceiving treatment. The OASH noted that many children with mental health problems in the United States do not getindividual, group, or family therapy, which was proven effective by research. (Office of Disease Prevention and HealthPromotion, n.d., b).
Legal and Ethical Considerations: Research has stated that it is important for a provider to determine the capacity of theadolescent receiving their care and also should follow their state’s guidelines regarding autonomy. Some states acknowledge the”mature minor” rule,
unemancipated adolescents who comprehend their disease and can make their own decisions on particular conditions. (Disla deJesus et al., 2023). In Massachusetts, children under 18 are minors and require parents’ or guardians’ permission before they get many types of medical treatment. Under Massachusetts’s mature minor(emancipated minor) rule, a provider may decide not tonotify the parents or guardians of the minor to whom they provide mental healthcare.
Minors 16 and 17 can consent to treatment in an inpatient mental health facility. (Mass.gov, n.d.). According to Disla de Jesuset al. (2023), a minor must provide assent, which is agreeing to receive the suggested treatment plan. S.B.’s mom signed hisconsent to treatment on admission to the clinic because he is 15 years old, and he provided assent to treatment. The patient was asked for permission to have his mother in the appointment room to promote treatment and appointment adherence.
Case Formulation and Treatment Plan:
(F43.23) Adjustment Disorder with mixed disturbance of emotions and conduct acute(Mild)/(51.01) Insomnia Disorder/(F90.2) ADHD predominantly hyperactive- impulsive type-in partial remission(mild):
Pharmacological Intervention: The patient will continue on his current medications. Vyvanse 10mg in the morning toimprove focusing and concentration, Propranolol 10mg, one tablet as needed for situational anxiety, Lamictal 25mg, threetablets(75mg) once a day mood stabilizer for adjustment disorder with mixed disturbance of emotions and conduct, and Clonidine 0.1mg tablet 1-2 times as needed at bedtime for insomnia. Medication teaching side effects were provided to thepatient and his mom. They were advised to report the side effects to the provider.
Nonpharmacological Intervention: He and his mom were encouraged to continue with his therapy sessions to learn positive coping skills to manage psychiatric diagnoses. Research has revealed that cognitive-behavioral therapy (CBT) is the most frequent form of treatment and the most recommended for Adjustment Disorder. (Quero et al., 2022). According to Lunsford-Avery et al. (2021), adolescents with insomnia are treated with behavioral therapies like behavioral therapy for insomnia (CBT-1), delivered individually or in groups combined with other CBT done by therapists. The patient was educated on sleep hygiene,such as turning all electronics and lights off to promote sufficient sleep health. Lunsford-Avery et al. (2021) stated that limiting electronic time before sleep and avoiding caffeinated drinks before bed are also helpful techniques.
ï His mother was advised to leave one Clonidine tab for the patient at night in case he needs it.
ï He was educated on the effects of nicotine vaping, and he verbalized understanding. He was applauded for not vaping again since three weeks ago.
ï He and his mom were encouraged to continue following up with his PCP.
ï He was educated on diet and exercise for weight management, stress management, and a healthy sleep schedule.
ï The patient was given the last 10 minutes of the interview for questions and answers, and he verbalized understanding.Active, supportive, attentive, and verbal listening were provided during the interview.
ï His follow-up appointment is in 4 weeks or sooner if needed. Risks and benefits were discussed with the patient, and he verbalized understanding. He was advised to call (508)872-3332, 988, or 911 or go to the nearest emergency roomwhen he feels unsafe.
PRECEPTOR VERFICIATION:
I confirm the patient used for this assignment is a patient that was seen and managed by the student at their Meditrek approved clinical site during this quarter course of learning.
Preceptor signature–:”-h_o=—-‘-r_h-Y’ C\_,K_’—–“=–_.._(‘(\_—=J– ,_ –=–c=Jc_ ——
Date:
References
American Psychiatric Association. (2022a). Trauma-and stressor-related disorders: Adjustment disorders. Diagnostic and statistical manual of mental disorders (5th ed., Text revision.). (pp. 319-320). American Psychiatric Association.
American Psychiatric Association. (2022b). Sleep-wake disorder: Insomnia disorder.
Diagnostic and statistical manual of mental disorders (5th ed., Text revision.). (pp. 409-410). American Psychiatric Association.
American Psychiatric Association. (2022c). Neurodevelopmental disorders: Attention-deficit/ Hyperactivitydisorder. Diagnostic and statistical manual of mental disorders (5th ed., Text revision.). (pp. 68-69). American Psychiatric Association.
Child Mind Institute. (n.d.). ADHD and sleep disorders: Are kids getting misdiagnosed? https://childmind.org/article/adhd-sleep-disorders-misdiagnosed/
Disla de Jesus, V., Liem, A., Borra, D., Jacob, M. & Appel, J.M. (2022). Who’s the boss?
Ethical dilemmas in the treatment of children and adolescents. Focus: The Journal of Lifelong
Learning in Psychiatry. 20(2). https://doi.org/10.ll76/appi.focus.20210037 Goldstone, A., Colrain, I. M., &Baker, F. C. (2018). Insomnia disorder in adolescence:
Diagnosis, impact, and treatment. Sleep medicine reviews, 39(12).
https://doi.org/10.1016/j.smrv.2017.06.009
Mass.gov. (n.d.). Consent to medical treatment by minors in Massacgusetts. A guide for practitioners. A Publication of BostonCollege Law School’s Juvenile Rights Advocates
Project. https://www.mass.gov/doc/consent-to-medical-treatment-by-minors-in–
massachusetts/download#:~:text=May%20minors%20consent%20to%20mental,a%20 mental%20health%20treatment%20facility.
MedlinePlus. (n.d.). Adjustment disorder. https://medlineplus.gov/ency/article/000932.htm Office of Disease Prevention andHealth Promotion. (n.d., a). Healthy People 2030: Social
determinants of health. US. Department of Health and Human Services.
https://health.gov/healthypeople/priority-areas/social-determinants-health Office of Disease Prevention andHealth Promotion. (n.d., b). Healthy People 2030:
Children. US. Department of Health and Human Services.
https://health.gov/healthypeople/objectives-and-data/browse-objectives/adolescents
Quero, S., Palau-Batet, M. Tur., C. Mor, S., Campos, D., Rachyla, I., Grimaldos, J. & Marco, J.
H. (2022). Effect of an Internet-based intervention for adjustment disorder on meaning in life and enjoyment. Curr Psychol (2022). https://doi.org/10.1007/s12144-022-031 77-w
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