Client Case Selection and Ensuring HIPAA Compliance in Clinical Settings

Client Case Selection and Ensuring HIPAA Compliance in Clinical Settings

PATIENT INFORMATION

Name: K.M

Age: 40 years

Gender at Birth: Male

Gender Identity: Male

Source: Patient

Race: Black American

Subjective:

CC (chief complaint): “I just can’t shake off this heavy feeling in my chest. It is like there is this darkness around me all the time, and I don’t see a way out. I have been feeling this way for four months, and it’s affecting everything in my life.”

HPI: K.M., a 40-year-old Black American male, is seeking psychiatric evaluation for a chief complaint of profound and persistent overwhelming sadness and hopelessness. This emotional burden has persisted for four months, significantly impacting various aspects of his life. The onset of symptoms has been gradual, with K.M. reporting a pervasive low mood, loss of interest in activities, disrupted appetite and weight, and disturbed sleep patterns. His subjective experience includes feelings of worthlessness and guilt, along with recurrent thoughts of death. Despite the duration, there has been no notable improvement in his emotional state.

K.M. notes a decline in concentration and decision-making abilities, adversely affecting his daily functioning. He emphasizes the pervasive nature of this emotional darkness, which permeates through all facets of his life. During the interview, no specific stressors are identified.

Past Psychiatric History:

• General Statement: M. reports no previous psychiatric history or involvement in mental health treatment. There is no documented evidence of prior psychiatric assessments, diagnoses, or interventions.
• Caregivers (if applicable): K.M. does not identify any involvement of caregivers in previous psychiatric care. He indicates a self-reliant approach to managing his mental health and has not sought support or assistance from family members or other caregivers.
• Hospitalizations: There is no history of psychiatric hospitalizations for K.M. He has not required inpatient care related to mental health concerns in the past.
• Medication trials: K.M. has not undergone any previous trials of psychiatric medications. He is not currently taking any psychotropic drugs, and there is no documented history of attempting pharmacological interventions for mood disorders or other mental health conditions.
• Psychotherapy or Previous Psychiatric Diagnosis: K.M. has not participated in psychotherapy or received any formal psychiatric diagnoses in the past. He reports no history of engagement in counselling or therapeutic interventions for emotional or psychological concerns.

Substance Current Use and History: K.M. consumes two cups of coffee daily but experiences no complications. He quit smoking two years ago and denies nicotine use. No illicit substances or marijuana use was reported. Occasional alcohol intake (1-2 drinks/week), last two days ago, with no withdrawal symptoms noted.

Family Psychiatric/Substance Use History: K.M. reports a family history free from known psychiatric or substance use disorders. He notes that immediate family members, including parents and siblings, have not experienced mental health challenges or struggled with substance abuse.

Psychosocial History: K.M. has a psychosocial background marked by stability in employment and a supportive social network. He works as a project manager, highlighting a successful career. However, despite professional achievements, K.M. describes pervasive feelings of isolation. He reports a limited social life and strained relationships, contributing to his sense of despair.

Medical History:

• Current Medications: K.M. is not currently prescribed any psychiatric or psychotropic medications. He is, however, regularly taking medication for hypertension. The prescribed antihypertensive medication includes lisinopril, 10 mg orally once daily, which he has been using for the past six months. There are no reported issues or side effects associated with this medication.
• Allergies: M. reports no known allergies to medications, food, or environmental factors.

• Reproductive Hx: K.M. reports a decrease in libido and a reduction in sexual activity. He reports that these changes have been present since the onset of his symptoms four months ago.

Review of Systems (ROS):

• GENERAL: K.M. reports fatigue, a pervasive sense of heaviness, and a notable decline in energy levels. He acknowledges disruptions in sleep patterns, experiencing difficulty falling and staying asleep.
• HEENT (Head, Eyes, Ears, Nose, Throat): M. denies any changes in vision, hearing, or throat discomfort.
• SKIN: No reported abnormalities, rashes, or changes in skin condition.
• CARDIOVASCULAR: M. denies chest pain, palpitations, or shortness of breath. RESPIRATORY: There are no complaints of cough, wheezing, or shortness of breath.
• GASTROINTESTINAL: M. reports a decrease in appetite and unintentional weight loss. He denies nausea, vomiting, abdominal pain, or changes in bowel habits.
• GENITOURINARY: No dysuria, hematuria, increased urinary frequency, or urgency.
• NEUROLOGICAL: M. reports difficulties with concentration and decision-making. No focal neurological deficits or seizures were reported.
• MUSCULOSKELETAL: No joint pain, stiffness, or muscle weakness was reported.
• HEMATOLOGIC: No history of bleeding disorders or abnormal bruising was reported.
• LYMPHATICS: M. denies swollen lymph nodes or pain in the lymphatic regions.
• ENDOCRINOLOGIC: No complaints of temperature intolerance, excessive thirst, or changes in skin and hair texture were reported.

Physical exam:

• GENERAL APPEARANCE:M. appears fatigued with a downcast demeanour. He demonstrates psychomotor retardation, moving slowly and exhibiting diminished overall energy.
• VITAL SIGNS: Blood pressure 148/95, heart rate 82 bpm, respiratory rate 16 bpm.
• NEUROLOGICAL: Oriented to person, place, and time. Normal muscle tone and strength. No focal neurological deficits were observed.
• HEENT (Head, Eyes, Ears, Nose, Throat): Pupils equal, round, and reactive to light. No signs of icterus, conjunctival pallor, or other abnormalities in the eyes, ears, nose, or throat.
• CARDIOVASCULAR: Regular rhythm, no murmurs or abnormal sounds upon auscultation. Peripheral pulses intact.
• RESPIRATORY: Clear breath sounds bilaterally. No wheezing, rales, or rhonchi were detected.
• GASTROINTESTINAL: Abdomen soft, non-tender, and non-distended. No palpable masses or organomegaly. Bowel sounds present.
• MUSCULOSKELETAL: No joint swelling, redness, or limitations in range of motion observed.
• SKIN: Normal skin colour and turgor. No rashes, lesions, or signs of trauma.

Mental Status Examination (MSE): K.M., a 40-year-old Black American male, appears fatigued and exhibits a downcast demeanour during the MSE. He is cooperative with the examiner, maintains a neat and clean appearance, and is dressed appropriately for the session. His psychomotor activity is notably slowed, demonstrating signs of psychomotor retardation. In terms of communication, K.M.’s speech is clear, coherent, and of normal volume and tone. However, there is a notable reduction in spontaneity and overall responsiveness, reflecting a diminished level of energy. His thought process appears goal-directed and logical, with no evidence of flight of ideas or looseness of association.

Mood assessment reveals a pervasive low mood, consistent with his chief complaint of severe depression. Affect is limited and flat, corresponding with his subjective emotional experience. Although he smiles at times, it is not congruent with the depth of his reported emotional distress. K.M. denies any auditory or visual hallucinations, and there is no evidence of delusional thinking. He states a lack of current suicidal or homicidal ideation. Cognitively, he is alert and oriented to person, place, and time. His recent and remote memory is intact, and concentration is notably compromised, consistent with reported difficulties in decision-making and focus. Insight and judgment into his condition are intact, as he attributes his symptoms to external stressors and acknowledges that he is sick and is ready to be assisted.

Objective:

Diagnostics:

1. Comprehensive Metabolic Panel (CMP) and Complete Blood Count (CBC): To rule out medical conditions that may mimic or exacerbate depressive symptoms. Abnormalities in electrolytes or blood cell counts could indicate underlying physical health issues (Sadock et al., 2015).
2. Thyroid Function Tests (TFTs): Thyroid dysfunction, particularly hypothyroidism, can manifest with symptoms similar to K.M.’s. TFTs will help rule out thyroid-related causes for K.M.’s mood disturbance (Sadock et al., 2015).
3. Patient Health Questionnaire-9 (PHQ-9): A standardized self-report tool to quantify and assess the severity of depressive symptoms. The PHQ-9 aids in establishing a baseline for symptomatology and monitoring changes over time (Gutiérrez-Rojas et al., 2020).
4. Hamilton Depression Rating Scale (HAM-D): A clinician-administered scale providing a more comprehensive evaluation of depressive symptoms, helping to corroborate the severity and nature of K.M.’s symptoms (Gutiérrez-Rojas et al., 2020).
5. Beck Depression Inventory-II (BDI-II): A self-report inventory to assess the intensity of depressive symptoms. The BDI-II will provide additional insight into K.M.’s emotional distress, complementing other diagnostic measures (Gutiérrez-Rojas et al., 2020).

Assessment

DSM-5 Diagnostic Assessment:

Major Depressive Disorder (MDD), Severe, without psychotic features (ICD-10-CM code: F32.2)

Rationale:

1. Symptom Criteria:M. presents with a pervasive low mood, anhedonia, disrupted sleep patterns, changes in appetite and weight, psychomotor retardation, and diminished concentration, consistent with the criteria outlined in DSM-5 for a diagnosis of Major Depressive Disorder (Gutiérrez-Rojas et al., 2020).
2. Duration and Severity: The symptoms reported by K.M. have persisted for four months, meeting the DSM-5 criterion for the duration of depressive episodes, which is at least two weeks. The severity is categorized as “Severe” based on the intensity and impact of the symptoms on various aspects of his life (Gutiérrez-Rojas et al., 2020).
3. Pertinent Positives and Negatives: Pertinent positives, including severe and persistent low mood, psychomotor retardation, and cognitive complaints, align with the DSM-5 criteria for MDD. Pertinent negatives, such as the absence of manic or hypomanic episodes and substance abuse, further support the specificity of the diagnostic impression (Gutiérrez-Rojas et al., 2020).

Differential Diagnoses:

1. Adjustment Disorder with Depressed Mood: Considered as a secondary differential due to reported stressors. However, the duration and intensity of the symptoms, along with the absence of a clear temporal relationship to specific stressors, make MDD a more fitting primary diagnosis (Schramm et al., 2020).
2. Dysthymic Disorder (Persistent Depressive Disorder): This is considered due to the chronic nature of K.M.’s symptoms. However, the severity and intensity of his current episode, along with the absence of a more prolonged history of milder symptoms, make MDD a more accurate diagnostic impression (Schramm et al., 2020).

Plan of Care:

1. Psychopharmacological Intervention:
   • Initiate sertraline 25mg daily for Major Depressive Disorder (MDD), Severe, without psychotic features. Discuss potential benefits, risks, and possible side effects, including nausea, insomnia, and sexual dysfunction (Gutiérrez-Rojas et al., 2020).
   • Emphasize the importance of consistent medication adherence. Instruct K.M. not to stop medication abruptly and to report any adverse reactions promptly.
2. Psychotherapy:
   • Commence Cognitive-Behavioral Therapy (CBT) sessions with a licensed therapist. Discuss the goals and expectations of therapy, emphasizing the collaborative nature of the therapeutic process (Gutiérrez-Rojas et al., 2020).
3. Lifestyle Modification and Social Support:
   • Collaborate with a physical therapist to develop an individualized exercise plan.
   • Provide education on sleep hygiene practices to address disrupted sleep patterns.
   • Provide health education on stress management, coping skills, and mindfulness techniques. Discuss preventive care measures to promote overall mental well-being.
   • Discuss the option of family therapy to involve family members in the treatment process (Zakhari, 2020).
4. Collaboration with Primary Care:
   • Coordinate with K.M.’s primary care provider for the management of chronic health conditions, particularly Hypertension. Ensure open communication to optimize overall health (Zakhari, 2020).
5. Continuous Monitoring and Follow-Up:
   • Allow time for questions and answers to assess K.M.’s understanding and agreement with the proposed plan. Document the client’s agreement to follow the treatment regimen.
   • Schedule regular follow-up appointments to monitor medication efficacy and therapy progress. Utilize standardized outcome measures such as the PHQ-9 and HAM-D to assess changes in symptoms over time (Zakhari, 2020).

6. Return to clinic:

• Return to the clinic after two weeks for review and therapy response monitoring.

References

Gutiérrez-Rojas, L., Porras-Segovia, A., Dunne, H., Andrade-González, N., & Cervilla, J. A. (2020). Prevalence and correlates of major depressive disorder: a systematic review. Brazilian Journal of Psychiatry, 42, 657-672. https://doi.org/10.1590/1516-4446-2020-0650

Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan & Sadock’s synopsis of psychiatry (11th ed.). Wolters Kluwer.

Schramm, E., Klein, D. N., Elsaesser, M., Furukawa, T. A., & Domschke, K. (2020). Review of dysthymia and persistent depressive disorder: history, correlates, and clinical implications. The Lancet Psychiatry, 7(9), 801-812. https://doi.org/10.1016/S2215-0366(20)30099-7

Zakhari, R. (2020). The psychiatric-mental health nurse practitioner certification review manual. Springer.

ORDER A PLAGIARISM-FREE PAPER HERE

We’ll write everything from scratch

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1. Instructions

   1. Select a client or case that you have worked with either in your current nursing practice or your PMHNP student clinical setting. Ensure that you correctly remove the appropriate information (name, etc.) to remain HIPAA compliant.
      

      Client Case Selection and Ensuring HIPAA Compliance in Clinical Settings

   2. Prepare a full mental health evaluation on your client. Use the resources presented in the course to help guide your evaluation. Kaplan & Saddock’s Synopsis of Psychiatry has a robust list of the categories of information you should collect and present in your evaluation report (5.1. Parts of the Initial Psychiatric Interview). This should include the following:
      1. A full psychiatric, physical, social, family, and work history including verbal reports of the client, your observations of the client, and a summary of any diagnostic aids that you have used.
      2. The use of at least one psychiatric screening or assessment tool from the literature to assist in your assessment of the client
      3. A full physical assessment in addition to the mental status exam and psychiatric history
   3. Develop a DSM-5 diagnostic assessment:
      1. Support your diagnosis through a thoughtful, evidence-based rationale of the data collected in your evaluation.
   4. Propose a practical, evidence-based plan of care:
      1. Keep in mind the role of the psychiatric-mental health nurse practitioner is to assess all aspects of the patient’s health status, including health promotion, and disease prevention. Psychiatric care is interdisciplinary. Your plan of care may include the use of other mental health professionals for the delivery of appropriate care. For example, someone who has been chronically back pain, and has been out of work may have these factors contributing to his or her depression and may require a pain specialist and social services to address those aspects of the client’s poor psychological functioning.

Requirements

1. 1. Support your assessment, diagnosis, and treatment and management plan with appropriate literature citations.
   2. The paper should be no more than ten pages in length, not including a title page and references.
   3. Use current APA formatting and citations.
   4. Acronyms should not be used.
   5. The assessment must be well-written and be of professional quality. It must be clear, and well-developed, free of spelling, grammatical, and syntactical errors and in full sentences format.

Requirements

1. Support your assessment, diagnosis, and treatment and management plan with appropriate literature citations.
2. The paper should be no more than ten pages in length, not including a title page and references.
3. Use current APA formatting and citations.
4. Acronyms should not be used.
5. The assessment must be well-written and be of professional quality. It must be clear, and well-developed, free of spelling, grammatical, and syntactical errors and in full sentences format.