Realistic Treatment Plan
For this assignment, you will develop a presentation on a realistic clinical case on a topic that was discussed in one of the discussions during weeks
Content Requirements Students will create a PowerPoint presentation with a realistic case study and include appropriate and pertinent clinical information that will be covering the following:
1. Subjective data:
· Chief Complaint
· Demographics
· History of the Present Illness (HPI) that includes the presenting problem and the 8 dimensions of the problem
· Review of Systems (ROS)
Elaborate on this data if it was not provided in the discussion post assignment.
2. Objective data:
· Medications
· Allergies
· Past medical history
· Family history
· Past surgical history
· Social history
· Labs
· Vital signs
· Physical exam
Elaborate on this data if it was not provided in the discussion post assignment.
3. Assessment:
· Primary Diagnosis
· Differential diagnosis
4. Plan:
· Pharmacologic treatment plan
· Non-pharmacologic treatment plan
· Follow up plan
5. Other:
· Incorporation of current clinical guidelines
· Integration of research articles
· Role of the Nurse practitioner
Submission Instructions:
· The presentation is original work and logically organized, formatted, and cited in the current APA style, including citation of references.
· The presentation should consist of 10-15 slides and less than 5 minutes in length.
· Incorporate a minimum of 4 current (published within the last five years) scholarly journal articles or primary legal sources (statutes, court opinions) within your work. Journal articles and books should be referenced according to the current APA style (the library has a copy of the APA Manual).
Includes a direct quote from patient about presenting problem
Begins with patient initials, age, race, ethnicity, and gender (5 demographics)
Includes the presenting problem and the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing and Severity)
Includes NKA (including = Drug, Environmental, Food, Herbal, and/or Latex or if allergies are present (reports for each severity of allergy AND description of allergy)
Includes a minimum of 3 assessments for each body system, assesses at least 9 body systems directed to chief complaint, AND uses the words “admits” and “denies”
Includes all 8 vital signs, (BP (with patient position), HR, RR, temperature (with Fahrenheit or Celsius and route of temperature collection), weight, height, BMI (or percentiles for pediatric population) and pain.)
Includes a list of the labs, diagnostic tests, or screening tools that should be completed for identified patient that are based on the US clinical guidelines OR acknowledges no labs/diagnostic tests are recommended.
Includes a list of all of the patient reported psychiatric and medical medications and the diagnosis for the medication (including name, dose, route, frequency)
Includes (Major/Chronic, Trauma, Hospitalizations), for each medical diagnosis, year of diagnosis and whether the diagnosis is active or current
Includes (Outpatient and Hospitalizations), for each psychiatric diagnosis (including addiction treatment), year of diagnosis
Includes an assessment of at least 6 family members regarding, at a minimum, genetic disorders, mood disorder, bipolar disorder and history of suicidal attempts
Distinguished Includes all 11 of the following: tobacco use, drug use, alcohol use, marital status, employment status, current and previous occupation, sexual orientation, sexually active, contraceptive use/pregnancy status, and living situation
Includes all 10 components of the mental status exam (appearance, attitude/behavior, mood, affect, speech, thought process, thought content/ perception, cognition, insight and judgement) with detailed descriptions for each area
Includes a clear outline of the accurate principal diagnosis based on DSM5 or DSM5-TR criteria
Includes at least 2 differential diagnoses for the principal diagnosis
Includes a detailed pharmacologic and non pharmacological treatment plan for each of the diagnoses listed under “assessment”. The plan includes ALL of the following: drug/vitamin/herbal name, dose, route, frequency, duration and cost as well as education related to pharmacologic agent. For non-pharmacological treatment, includes: treatment name, frequency, duration. If the diagnosis is a chronic problem, student includes instructions on currently prescribed medications as above.
Provides a detailed list of medical and other interdisciplinary referrals or documents NO REFERRAL ADVISED AT THIS TIME. Includes a timeline for follow up appointments.
Effectively uses literature and other resources to inform their work. Exceptional use of citations and extended referencing. High level of precision with APA 7th Edition writing style.
Case Study Discussion
Helen is a 45-year-old African American woman who has recently separated from her husband of 25 years. She is struggling with increased anxiety, sadness, guilt, and fatigue, and has lost her appetite. Helen has difficulty functioning and feels that life is not worth living, but she has not had any suicidal ideation. She has no family or personal psychiatric illness history. Helen’s symptoms began three months ago after her husband had an extramarital affair. Her symptoms have been progressing over the past four weeks to inappropriate guilt, increasing sadness, decreased energy levels, and poor appetite. Helen has been struggling to maintain her normal daily activities and has started feeling that “life is not worth living,” but she has not experienced any suicidal ideation.
Helen’s DSM5 diagnosis is Major Depressive Disorder. The rationale for this diagnosis is that Helen has experienced a loss (separation from her husband), and she has symptoms of depressed mood and decreased energy levels (Gutiérrez-Rojas et al., 2020, p. 658). She also has a poor appetite and difficulty sleeping for at least two weeks, and her symptoms are causing her significant distress and impairment in functioning.
The most appropriate pharmacological treatment to prescribe for Helen is an antidepressant medication. The rationale for this treatment is that antidepressants are the most effective medication for treating major depressive disorder (Zuckerman et al., 2018, p. 655). There are several different types of antidepressant medications that can be prescribed, such as SSRIs, SNRIs, and tricyclic antidepressants. Fluoxetine, an SSRI, can be given 20mg once a day. The medication inhibits serotonin reuptake.
The most appropriate non-pharmacological treatment to prescribe for Helen is psychoeducation. The rationale for this treatment is that psychoeducation can help Helen to understand her diagnosis and learn about treatment options, which can empower her to make informed decisions about her care. Psychoeducation can reduce the risk of relapse and improve treatment outcomes (Katsuki et al., 2018, p. 9). Psychoeducation can also help to reduce the stigma associated with mental illness, which can encourage Helen to seek help and follow her treatment plan. Psychoeducation can be delivered in a group setting or individual sessions. Group psychoeducation can provide patients with support and information from other people who are going through similar experiences. Individual psychoeducation can be tailored to the specific needs of the patient and can provide a more intimate setting for learning.
Medication appropriateness, cost, effectiveness, safety, and potential for patient adherence are all important factors to consider when prescribing medication for a mental health disorder. Antidepressants are generally considered to be safe and effective for the treatment of the major depressive disorder, with a low potential for abuse or dependence. However, some people may experience side effects when taking antidepressants, such as nausea, weight gain, and sexual dysfunction (Zuckerman et al., 2018, p. 655). The cost of antidepressant medication can vary depending on the specific medication prescribed, as well as the patient’s insurance coverage. In some cases, generic versions of antidepressant medication may be available, which can help to reduce the cost of treatment. Patient adherence is another important factor when prescribing medication for a mental health disorder. Non-adherence to medication can lead to treatment resistance and an increased risk of relapse. Several factors can contribute to non-adherence, such as cost, side effects, and forgetfulness. Psychoeducation can help to empower patients and reduce the stigma associated with mental illness, which can encourage patients to adhere to their treatment plan.
The cost of the medication will be determined by the prescribing physician and the local pharmacy. The cost of antidepressant medications can vary depending on the type of medication prescribed. For example, generic SSRIs can cost as little as $4 per month, while brand-name SNRIs can cost up to $250 per month.