NU665C – Week 15 Case Study AnalysisFor this assignment, you will apply what you have learned during the course to develop and present a case and treatment plan for a fictional or real client encountered in clinical practice. Your case analysis will be completed in three sections totaling five to seven pages (excluding title page and references) and will be graded using the case study grading rubric. Part A: Clinical AssessmentRecord your client assessment, diagnosis (medical and psychiatric differentials), medical and psychiatric history and psychosocial factors that impact the case. This information should be presented in the same format as your Wheeler (2014) textbook’s Sample Clinical Assessment Form, found on pages 143–145.Conclude Part A with a one-page description of this fictional patient, including all the relevant information outlined in the clinical assessment form as well as relevant and realistic information acquired from your research. Refer to the APA Clinical Practice Guidelines.Part B: Therapy SessionYou will design a therapy session for your client based on his or her preceding clinical assessment. Part B of your assignment will be assessed on your demonstration of proper therapeutic communication. The empathy demonstrated should be consistent with the following operational definition: Empathy is a critical tool for establishing a trusting therapeutic relationship. Rather than parrot back what your client has said, good empathy reflects the thoughts and feelings of your client and notes the importance of what has been communicated. In doing so, it invites the client to self-explore. Empathic feedback avoids “why” questions. When appropriately relayed in a tentative manner, good therapeutic empathy also gives the client a chance to redirect or correct what the counselor has said. Your session transcript should:Use your personal experiences to replicate realistic patient responses as well as clinical responses. Be a written transcript of more than 2,100 words (at least 15 minutes in length). Evidence empathic feedback that adheres to the operational definition of empathy in the counselor’s responses to most of the client’s remarks. Part C: Therapeutic InterventionMuch of the information you learn through your research can help inform the development of your patient. Research evidence-based interventions involving both psychopharmacological and nonpharmacological services to individuals who have been assessed in a mental health setting. There should be three to five evidence-based articles and interventions that encompass both medication and non-medication modalities. Be sure to include two different therapeutic approaches when discussing non-medication interventions. For example, when selecting therapeutic approaches, you can select client-centered and cognitive behavioral therapy.
wheeler_3_of_3.jpg
nu665c__case_study_rubric.pdf
wiltin_20190721_psychiatric_progress_note.pdf
wiltin_20191125_psychiatric_progress_note.pdf
wiltin_20191205_psychiatric_progress_note.pdf
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NU665C: Case Study Rubric
NU665C: Case Study Rubric – 100 Points
Criteria
Exemplary
Exceeds Expectations
Advanced
Meets Expectations
Psychiatric
Assessment
Takes a comprehensive
approach for assessing
case study with higher-level
thinking.
Addresses categories
with adequate
responses.
17 points
20 points
Intermediate
Needs
Improvement
Makes an attempt
to assess case
study client but
shows minimal
ability to analyze
situation.
Novice
Inadequate
Total
Points
Unable to address
assessment
category in an
understandable
manner.
20
13 points
15 points
Diagnosis
(Primary and
Differential)
Demonstrates evidence of
critical thinking at an
advanced practice level.
Demonstrates some
use of critical thinking
at the advanced
practice level.
20 points
Limited
demonstration of
critical thinking at
the advanced
practice level.
Shows no higherlevel thinking.
20
13 points
17 points
15 points
Biopsychosocial
Case Formulation
Presents information in a
systematic manner and
uses logical format with
clear objectives and
planning.
Presents information
in a reasonable
manner that implies
some higher-level
understanding.
Presents
information without
full clarity of the
clinical situation.
Unable to
articulate
understanding of
the clinical subject
matter.
20
15 points
Treatment Plan,
Implementation,
Coordination,
Health Teaching
& Promotion
20 points
17 points
High level of conceptual
understanding of the
advanced practice role in
planning sound treatment,
utilizing management
techniques, client teaching,
and health promotion
approaches.
Demonstrates
adequate
understanding of the
clinical situation,
sound teaching, and
health promotion
approaches.
17 points
13 points
Demonstrates
minimal
understanding of
the clinical
management
system, teaching,
and health
promotion
activities.
Unable to
implement or
understand
implementation
and coordination
of care, teaching,
or health
promotion
activities.
15 points
13 points
Minimal use of
evidence and
limited
understanding of
outcome
measures. Relies
only on classroom
textbooks as
references.
No demonstration
of evidence-based
practice. Does not
support practice
decisions with
references.
20
20 points
Outcomes and
Evidence-based
Resources
Demonstrates
comprehensive use of
evidence to support metrics
and practice tools. Uses
more than three researchbased references.
10 points
Demonstrates
appropriate use of
evidence to support
practice/outcome
measures. Uses a
minimum of three
research-based
references.
10
6 points
8 points
7 points
Grammar/Spelling
Author makes no significant
errors in grammar or
spelling that distract the
reader from the content
5 points
Author makes no
significant errors in
grammar or spelling
that distract the
reader from the
content
Author makes
minor errors in
grammar or
spelling that
distract the reader
from the content
Author makes
several errors in
grammar or
spelling that
distract the reader
from the content
5
APA Format
4 points
3 points
2 points
Follows APA 100% of the
time
Follows APA 90-99%
of the time
Follows APA 8089% of the time
Follows APA less
than 80% of the
time
5 points
4 points
3 points
5
2 points
Total points
100
Desert Sage Behavioral Health
7090 N Oracle Rd #178-203
Tucson AZ 85704-4333
(520) 468-1302
Client ID: WILTIN
Patient: TINA WILSON
Patient DOB:12/4/1968
Provider:Daniel P. Chafetz, PNP
Appointment Start Time:7/21/2019 3:00:00 PM
Appointment End Time:7/21/2019 3:15:00 PM
Appointment Duration:15 minutes
Primary Code:99308
Add-on code 1:
Add-on code 2:
POS:31
Modifiers:
Persons Present in Session
The patient was present in the session. The patient , who is not a medical decision maker, was
present via tele-conference.
The patient’s other caregiver, Dawn, who is a medical decision maker, was present via teleconference in the session.
Meds
Medication
sertraline
quetiapine
gabapentin
benztropine
Dosage
x0: 100 mg tablet
x0: 300 mg tablet
x0: 300 mg capsule
x0: 1 mg tablet
Allergies
Allergy
penicillin v potassium
Sig
Prescriber
Reaction
Hives
Chief Complaint
Follow up
History of Present Illness/Interval History
Attempted to complete telemed appointment several of times, but was unable to get connected.
Patient’s sister reports that there are no changes in the patient’s mood. Sister is concerned about the
care the patient is getting in the facility and reports that she is trying to get her home soon. Reports
that she is only supposed to be on tube feeding for 4 hours, but the patient reports that it is on all
day. Sister is also concerned about the staff not turning the patient or ensuring to offer her hydration,
as she is unable to do by herself. Discussed contacting case manager regarding concerns. Discussed
with sister that Genesight results not yet available. Discussed other alternatives for patient to be
seen.
Stressors
Areas of stress included the following: severe stress due to occupational and health concerns,
moderate stress due to family concerns, and mild stress due to friends concerns. There was no stress
reported in the following areas: relationship, educational, economic, housing, and legal concerns.
Past History
WILTIN_20190721_Psychiatric Progress Note.pdf
Page | 1 of 4
Past, Family, and Social History remain unchanged as captured on intake and former session
documents.
Review of Systems
The patient reported fatigue/lethargy and sleeping pattern disruption but no other constitutional
issues. The patient reported swelling in joints and redness of joints but no other musculoskeletal
issues. The patient reported difficulty swallowing solids or liquids and abdominal pain but no other
gastrointestinal issues. The patient reported numbness/tingling sensations but no other neurological
issues. The patient reported feeling depressed and anxiety but no other psychiatric issues.
Other than previously stated, the review of systems and organs is noncontributory for eyes,
ears/nose/mouth/throat, cardiovascular, respiratory, allergic/immunologic, hematologic/lymphatic,
sex-specific genitourinary, integumentary, and endocrine issues.
Exam
Appearance:
Behavior:
Speech:
Mood:
Thought process:
Thought content:
Insight/Judgment:
Consciousness:
Orientation:
Recent Memory:
Remote Memory:
Attention/Conc:
Language (Naming):
Language (Repeating
Phrase):
Language (Abstraction):
Fund of Knowledge:
Gait / Station:
Muscle Strength:
Muscle Tone:
Appropriate Dress Adequate Grooming and Hygiene
Cooperative Good Eye Contact Normal Psychomotor
Activity
Normal Rate, Amplitude, and Prosody
Sad/Depressed Anxious
Goal Directed Organized Logical
No Abnormal Content Future Oriented
Intact
Alert / Awake
Ox3
Intact
Intact
Intact
Intact
Intact:
Abstract:
Excellent
NL
NL
NL
Sources of Information
The patient was a source of information used to complete the history documented in this note.
Another family member was a source of information used to complete the history documented in
this note.
Assessment – Sources of Risk
• No evidence of acute risk of harm to self or others
WILTIN_20190721_Psychiatric Progress Note.pdf
Page | 2 of 4
Suicide Risk Factors
• The patient was screened for the following risk factors: prior attempt; current attempt; history of
medically serious attempt; recent psychiatric hospital discharge; recent loss (particularly
interpersonal or fall in social status); currently diagnosed with Major Depression; currently
diminished concentration or indecision (Cognitive Impairment); current sleep problems; currently
experiencing hopelessness; currently experiencing panic or significant anxiety; psychotic symptoms
or underlying thought disorder or loss of rational thought (i.e., dementia); currently diagnosed with
Borderline Personality Disorder; current ETOH or drug use; history of impulsivity; intense level of
agitation; actively making death arrangements (updated will, suicide note, recently purchased life
insurance, giving away possessions, etc.); lethal methods available or easily obtained; likely to be
alone, currently socially isolated; family member committed suicide; history of childhood sexual
abuse; unemployed; financial strain; and physical illness.
The following risk factors for suicide/self harm exist for this patient:
Suicide Protective Factors
The following protective factors from suicide/self harm exist for this patient:
• Actively making future plans
Suicide Prevention Plan
The following plan was formulated based on the risk and protective factors identified and the need to
lower the probability of suicide.
• Patient has someone living with them
• Patient is receiving treatment for depression
Assessment
Diagnoses
DSM-5 Diagnoses
296.30
Major depressive disorder,
Recurrent episode, Unspecified
309.81
Posttraumatic stress disorder
F33.9
F43.10
Major depressive disorder,
Recurrent episode, Unspecified
Posttraumatic stress disorder
DSM-5 Other Conditions
No assigned diagnoses
General Medical & Non-DSM-5 Diagnoses
No assigned diagnoses
WILTIN_20190721_Psychiatric Progress Note.pdf
Page | 3 of 4
Impression
depressed and sad
Informed Consent
The patient gave informed consent for the treatment documented in this clinical note. We discussed
privacy policies and clinic policies, including cancellation policies. We discussed the benefits and
risks of medication, including precautions and potential side effects and/or adverse reactions.
Counseling and Coordination of Care
Greater than 50% of session was spent on counseling and/or coordination of care.
Counseling provided to the patient/caregiver as outlined below. Addressed patient/caregiver
concerns regarding current medication regimen including effectiveness. Addressed patient/caregiver
concerns regarding diagnosis and prognosis including accuracy of diagnosis and prognosis over
time.
Psychotherapy
• Supportive Therapy
Plan
• Continue current psychotherapy focus
Pending Genesight results. Considering alternative options for telemed.
Medication Changes
(no medication changes)
Labs Ordered
genesight
Next Appointment
(no appointment scheduled)
• Caregiver will contact office for next appointment
Electronically signed on 8/26/2019 12:48:37 PM by Daniel P. Chafetz, PNP.
WILTIN_20190721_Psychiatric Progress Note.pdf
Page | 4 of 4
Desert Sage Behavioral Health
2101 E. Grant Rd
Tucson AZ 85719-3412
(520) 468-1302
Client ID: WILTIN
Patient: TINA WILSON
Patient DOB:12/4/1968
Provider:Daniel P. Chafetz, PNP
Appointment Start Time:11/25/2019 10:30:00 AM
Appointment End Time:11/25/2019 11:00:00 AM
Appointment Duration:30 minutes
Primary Code:99214
Add-on code 1:
Add-on code 2:
POS:11
Modifiers:
Persons Present in Session
The patient was present in the session. The patient , who is not a medical decision maker, was
present via tele-conference.
The patient’s other caregiver, Dawn, who is a medical decision maker, was present via teleconference in the session.
Meds
Medication
benztropine
gabapentin
sertraline
Dosage
x0: 1 mg tablet
x0: 300 mg capsule
x0: 100 mg tablet
Allergies
Allergy
penicillin v potassium
Sig
Prescriber
Reaction
Hives
Chief Complaint
Follow up
History of Present Illness/Interval History
Attempted to complete telemed appointment several of times, but was unable to get connected.
Patient’s sister reports that there are no changes in the patient’s mood. Sister is concerned about the
care the patient is getting in the facility and reports that she is trying to get her home soon. Reports
that she is only supposed to be on tube feeding for 4 hours, but the patient reports that it is on all
day. Sister is also concerned about the staff not turning the patient or ensuring to offer her hydration,
as she is unable to do by herself. Discussed contacting case manager regarding concerns. Discussed
with sister that Genesight results not yet available. Discussed other alternatives for patient to be
seen. cant open genesight results and will attempt next week.
Stressors
Areas of stress included the following: severe stress due to occupational and health concerns,
moderate stress due to family concerns, and mild stress due to friends concerns. There was no stress
reported in the following areas: relationship, educational, economic, housing, and legal concerns.
Past History
Past, Family, and Social History remain unchanged as captured on intake and former session
documents.
WILTIN_20191125_Psychiatric Progress Note.pdf
Page | 1 of 5
Review of Systems
The patient reported fatigue/lethargy and sleeping pattern disruption but no other constitutional
issues. The patient reported swelling in joints and redness of joints but no other musculoskeletal
issues. The patient reported difficulty swallowing solids or liquids and abdominal pain but no other
gastrointestinal issues. The patient reported numbness/tingling sensations but no other neurological
issues. The patient reported feeling depressed and anxiety but no other psychiatric issues.
Other than previously stated, the review of systems and organs is noncontributory for eyes,
ears/nose/mouth/throat, cardiovascular, respiratory, allergic/immunologic, hematologic/lymphatic,
sex-specific genitourinary, integumentary, and endocrine issues.
Vital Signs
Previous
Vital
Signs
Current
Vital
Signs
BP
07/11/2019:
134/86
mm[Hg]
108/68
Exam
Appearance:
Behavior:
Speech:
Mood:
Thought process:
Thought content:
Insight/Judgment:
Consciousness:
Orientation:
Recent Memory:
Remote Memory:
Attention/Conc:
Language (Naming):
Language (Repeating
Phrase):
Language (Abstraction):
Fund of Knowledge:
Gait / Station:
Muscle Strength:
Muscle Tone:
HR
Respiration
07/11/2019: 07/11/2019:
88 /min
20 breaths
per minute
78
18
Height
Weight
BMI
07/11/2019: 07/11/2019: 07/11/2019:
65 in
125 lb
20.8 kg/m2
64
110
11/25/2019:
18.9 kg/m2
Appropriate Dress Adequate Grooming and Hygiene
Cooperative Good Eye Contact Normal Psychomotor
Activity
Normal Rate, Amplitude, and Prosody
Sad/Depressed Anxious
Goal Directed Organized Logical
No Abnormal Content Future Oriented
Intact
Alert / Awake
Ox3
Intact
Intact
Intact
Intact
Intact:
Abstract:
Excellent
NL
NL
NL
Sources of Information
The patient was a source of information used to complete the history documented in this note.
WILTIN_20191125_Psychiatric Progress Note.pdf
Page | 2 of 5
Another family member was a source of information used to complete the history documented in
this note.
Assessment – Sources of Risk
• No evidence of acute risk of harm to self or others
Suicide Ideation Intensity
The patient reported having thoughts of wanting to die or killing themselves once a week and that
these thoughts last less than 1 hour (some of the time). With respect to the patient’s ability to stop
thinking about killing themselves or wanting to die, the patient reported that they can control these
thoughts with little difficulty. With respect to potential deterrents which stopped them from wanting
to die or acting on thoughts of committing suicide, the patient reported that deterrents probably
stopped them from attempting suicide. The patient reported that their reasons for wanting to die or
killing themselves was mostly to end or stop the pain (they couldn’t go on living with the pain or
how they were feeling).
Suicide Risk Factors
• The patient was screened for the following risk factors: prior attempt; current attempt; history of
medically serious attempt; recent psychiatric hospital discharge; recent loss (particularly
interpersonal or fall in social status); currently diagnosed with Major Depression; currently
diminished concentration or indecision (Cognitive Impairment); current sleep problems; currently
experiencing hopelessness; currently experiencing panic or significant anxiety; psychotic symptoms
or underlying thought disorder or loss of rational thought (i.e., dementia); currently diagnosed with
Borderline Personality Disorder; current ETOH or drug use; history of impulsivity; intense level of
agitation; actively making death arrangements (updated will, suicide note, recently purchased life
insurance, giving away possessions, etc.); lethal methods available or easily obtained; likely to be
alone, currently socially isolated; family member committed suicide; history of childhood sexual
abuse; unemployed; financial strain; and physical illness.
The following risk factors for suicide/self harm exist for this patient:
Suicide Protective Factors
The following protective factors from suicide/self harm exist for this patient:
• Actively making future plans
Suicide Prevention Plan
The following plan was formulated based on the risk and protective factors identified and the need to
lower the probability of suicide.
• Patient has someone living with them
• Patient is receiving treatment for depression
WILTIN_20191125_Psychiatric Progress Note.pdf
Page | 3 of 5
Assessment
Diagnoses
DSM-5 Diagnoses
296.30
Major depressive disorder,
Recurrent episode, Unspecified
309.81
Posttraumatic stress disorder
F33.9
F43.10
Major depressive disorder,
Recurrent episode, Unspecified
Posttraumatic stress disorder
DSM-5 Other Conditions
No assigned diagnoses
General Medical & Non-DSM-5 Diagnoses
No assigned diagnoses
Impression
depressed and sad
Informed Consent
The patient gave informed consent for the treatment documented in this clinical note. We discussed
privacy policies and clinic policies, including cancellation policies. We discussed the benefits and
risks of medication, including precautions and potential side effects and/or adverse reactions.
Counseling and Coordination of Care
Greater than 50% of session was spent on counseling and/or coordination of care.
Counseling provided to the patient/caregiver as outlined below. Addressed patient/caregiver
concerns regarding current medication regimen including effectiveness. Addressed patient/caregiver
concerns regarding diagnosis and prognosis including accuracy of diagnosis and prognosis over
time.
Psychotherapy
• Supportive Therapy
Plan
• Continue current psychotherapy focus
Pending Genesight results. Considering alternative options for telemed.
Medication Changes
WILTIN_20191125_Psychiatric Progress Note.pdf
Page | 4 of 5
Medication Dosage
benztropine x0: 1 mg tablet
gabapentin x0: 300 mg
capsule
sertraline
x0: 100 mg
tablet
benztropine x60: 1 mg
tablet
gabapentin x90: 300 mg
capsule
sertraline
x30: 100 mg
tablet
Sig
Prescriber
Action
Discontinue
Discontinue
Discontinue
1 tablet by mouth twice a day as
directed
1 capsule by mouth three times a
day as directed
1 tablet by mouth once a day as
directed
Daniel
Chafetz
Daniel
Chafetz
Daniel
Chafetz
New Order
New Order
New Order
Labs Ordered
genesight
Next Appointment
(no appointment scheduled)
one week
Electronically signed on 11/25/2019 11:49:33 AM by Daniel P. Chafetz, PNP.
WILTIN_20191125_Psychiatric Progress Note.pdf
Page | 5 of 5
Desert Sage Behavioral Health
7090 N Oracle Rd Suite#178-203
Tucson AZ 85704-4333
(520) 468-1302
Client ID: WILTIN
Patient: TINA WILSON
Patient DOB:12/4/1968
Provider:Daniel P. Chafetz, PNP
Appointment Start Time:12/5/2019 11:00:00 AM
Appointment End Time:12/5/2019 11:15:00 AM
Appointment Duration:15 minutes
Primary Code:99213
Add-on code 1:
Add-on code 2:
POS:11
Modifiers:
Persons Present in Session
The patient was present in the session. The patient , who is not a medical decision maker, was
present via tele-conference.
The patient’s other caregiver, Dawn, who is a medical decision maker, was present via teleconference in the session.
Meds
Medication Dosage
benztropine x60: 1 mg tablet
gabapentin
sertraline
x90: 300 mg
capsule
x30: 100 mg tablet
Sig
1 tablet by mouth twice a day as directed
1 capsule by mouth three times a day as
directed
1 tablet by mouth once a day as directed
Allergies
Allergy
penicillin v potassium
Prescriber
Daniel
Chafetz
Daniel
Chafetz
Daniel
Chafetz
Reaction
Hives
Chief Complaint
Follow up
History of Present Illness/Interval History
Attempted to complete telemed appointment several of times, but was unable to get connected.
Patient’s sister reports that …
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