Posted: February 26th, 2023

Learning More

What are the three most important things you learned this week?

What questions remain uppermost in your mind?

Is there anything you did not understand?

Just a few sentences for each question based on powerpoint

NURS 521

Feb 13, 2022 class

Today’s schedule

0900-0910: Complete quiz if needed

Review this week

Self-disclosure/direct question from patient

MSE – Carlat ch 21 and 27, resources in Canvas

Lifespan case study assignment resubmission

Differential diagnosis activity

Treatment planning activity

A mindful walk activity

Review next module

Lab:

Psych interview role play practice

Psychiatric review of symptoms (Carlat starting on p.124)
Mood disorders: How would you describe your mood recently? OR have you been feeling depressed? Do you ever feel sad and down? Have you had any periods where you felt like you had too much energy?
SIGE-CAPS, DIGFAST
Psychotic disorders: Have you had any issues with hearing voices/seeing things? Any issues with unusual beliefs that other people didn’t share? Have you ever thought anyone was out to get you?
Substance use disorders: Has anyone ever criticized you for your substance use? (after substance use assessment) Have any of these every caused problems in your life?
Anxiety disorders: Any issues with anxiety? Do you tend to be a nervous person?
Obsessive-compulsive disorders: Are there things you feel like you have to do in certain situations? Are there specific things you tend to worry about? Do you have thoughts that you feel like you can’t control?
Eating disorders: Have you ever felt like you were overweight? Have you ever dieted? Do you ever restrict your food intake intentionally? Do you ever vomit or purge after eating? How would you describe your relationship with food and eating?
Neurodevelopmental disorders: Tell me about how school went for you when you were growing up. How is your focus and concentration?
Neurocognitive disorders: Any issues with your memory? Do you find that you have trouble remembering things? Has anyone else mentioned that you are having trouble with your memory?
Personality disorders: Tell me about your work history. Tell me about your relationships with others. How would you describe your relationships with others.

Clinical decision making tool

Differential diagnosis activity
41 year old cisgender woman presents for evaluation
CC: “I’ve been depressed.”
Presenting symptoms: Depressed mood, tearfulness, passive suicidal thoughts, lack of motivation and energy, frequent rumination and worrying, difficulty falling asleep
Course of illness: Symptoms have been present off and on since she was a teenager, most recently have worsened in the past 6 months
MSE: Presents with restricted affect, depressed mood, well-groomed and appropriately dressed, linear and logical thought process, + for passive SI, – for HI or psychosis, insight and judgment are good, attention and concentration are good in the interview
Functionality: Has maintained work as an accountant, more isolative and less social with friends
Past treatment history: Has been treated with antidepressant medication in the past, no medications for about 3 years, did some therapy after college but none since then
How would we diagnose this patient?

What additional information do you need?
Psych review of symptoms
Manic/hypomanic: no
Appetite issues: no
Diurnal variation to symptoms? No, constant throughout the day
Anxiety symptoms: ruminating and worrying about work stressors, no physical symptoms of anxiety (HR, SOB, jittery, etc.)
Substance use: ETOH 2 drinks twice a week, nothing else
Trigger? Did anything happen/change 6 months ago
More thorough assessment of SI and past history: no hx of attempts, no plan, no intent, no self-harm
Med history
Relationships, work history: no issues, WNL
Trauma history: none
More info on course of illness: “I don’t really know. I can’t remember.”
Social history: more detail
Family history: mom has depression, brother has anxiety, nothing else
Labs: no abnormalities
Any other medical conditions: no

What would be on your initial differential?
Major depressive disorder: Does not have enough symptoms
Dysthymia: Symptoms have not been constant for long enough (two years)
Unspecified depressive disorder
Adjustment disorder with depressed mood: No recent stressor
Trauma related disorder: No history of trauma
Anxiety disorder: Does not have sufficient symptoms
Bipolar disorder: No history of manic or hypomanic symptoms
Substance related disorder: No substance use, no other medications that could contribute to sx’s
Depressive disorder due to a medical condition – hypothyroid, vitamin D deficiency, anemia, pregnancy: No lab findings

Which diagnosis fits best?
Unspecified depressive disorder

Treatment planning activity
Class will divide into 6 groups
Each group is assigned to one case
Discuss your case as a group and determine your treatment recommendation
Assume that the patient is open to whatever treatment plan you recommend
Each group present your case, recommendation, and rationale

Recommendations
Basically okay. Outpatient treatment is not necessary.
Mild disturbance. Outpatient treatment should be considered.
Significant disturbance. Outpatient treatment is definitely recommended.
Severe disturbance. Consider hospitalization.

Group 1
Bob is a 25 year old member of a religious organization that is based in Buddhism. Bob’s working for this organization caused considerable conflict between him and his parents, who are devout Catholics. Recently Bob experiences acute spells of nausea and fatigue that prevent him from working and which have forced him to return home to live with his parents. Various medical tests are being conducted, but as of yet, no physical causes of his problems have been found.

Group 2
Mary is a 36 year old musician who is very dedicated and successful in her work as a teacher in a local high school and as a part time member of local musical groups. Since her marriage five years ago, which ended in divorce, she has dated very few people. She often worries that her time is “running out” for establishing a romantic relationship, getting married, and having children, and she would very much like to do these things. Her friends tell her that she gets way too anxious when around people she is interested in dating and that she needs to relax a little in general.

Group 3
Jim was vice president of the first year class at a local college and played on the school’s football team. Later that year he dropped out of these activities and gradually became more withdrawn from friends and family. Neglecting to shave and shower, he began to look dirty and unhealthy. He spent most of this time alone in his room and sometimes complained that he heard voices in the curtains and in the closet. In his second year, he dropped out of school entirely. With increasing anxiety, he began to worry that the “Nazis” were plotting to kill his family and kidnap him.

Group 4
Allison is a 15 year old girl who has been experiencing some conflict with her parents related to a friend she has been spending a lot of time with. Her parents are concerned that this friend is a negative influence on Allison, because the two of them have skipped school a few times together. When her parents express concern about this, Allison dramatically shouts “well what’s the point of living anymore if you’re going to control my every move” and goes into her room and slams the door.

Group 5
Jeff is an 82 year old retired teacher whose wife of 45 years died of cancer about 2 months ago. Jeff spends a lot of his time at home looking at pictures and mementos from his marriage. His pastor, family members, and friends come to visit several times a week and bring him meals, and he spends time talking with them when they are visiting. He says he doesn’t feel like going out and wishes he could be with his wife in heaven.

Group 6
Alex is a college professor who recently completed their PhD and started a new teaching job. They have been very focused on planning courses and syllabi for the upcoming semester and have been staying up until 5 or 6am working on lesson plans and course materials most nights for the past couple of weeks. They have also been engaging in behavior unusual for them such as going out to bars and drinking a lot more than usual and online shopping. Their friends and family members start to get concerned when Alex sends out a mass email discussing their plans to run for city council and make some big changes in the local government.

A mindful walk
Take a walk outside for 10-15 minutes
Focus on observing with all of your senses as you are walking
Notice what you experience and observe
When you get back, spend a few minutes writing down everything you observed during the walk