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History of Present Illness Narrative (Including OLDCARTS-generated data from the patient) HPI: Mr. Smith is a 62-year-old good historian and widower who currently lives alone. He states that his son has recommended he be seen today due to feeling down since his wife passed away 1.5 years ago. He reports this is the first time he has ever been seen for his symptoms. He has felt down all day every day since her passing and “a big part of me died when she did, and its like its not worth living without her anymore”. He reports that he has never attempted suicide but “wouldn’t mind going to sleep and not waking up”. He denies having plans to hurt himself stating, “No I could never do that to my kids, I couldn’t take away both their parents”. He denies plans to hurt himself. He denies homicidal thoughts. He reports he used to attend church but has lost interest since his wife passed. He denies treatment for his symptoms in the past. He reports feeling worse on her birthday or on anniversaries. He reports that nothing has improved his mood. His symptoms have caused him to decrease his hours at work to part time. He reports he can perform day to day tasks and take care of himself. He denies previous diagnosis of depression in the past. He reports he can hear his wife at times but knows she is not actually there, and it is not her actual voice. He has 5 children that live in the same town, and he feels they are reliable support for him. He states they invite him places, he just doesn’t feel like going out anymore. It’s like everything has kind of lost its meaning. Date of Visit 7/30/202 5 OSCE # 4 Panopto Video Link https://wgu.hosted.panopto.com/Panopto/Pages/Viewer.aspx?id=5acfad92-bde8- 4560 - 91d0- b1bd
PATIENT INFORMATION
Name Gerlad Smith DOB 11/1/ Sex Male
SUBJECTIVE
Chief Complaint “My son thought I should come just because I’ve been down for a while since my wife passed away”. Psychiatric History (hospitalizations, evaluations, suicide attempts) Denies past psychiatric history. Denies previous diagnosis of depression or any other mental illness. Had never been hospitalized or on any medications for depression or other mental illnesses in the past. Denies suicide attempts. No past evaluations. Substance Use (Drug, Alcohol, Tobacco and Vape, Caffeine) Denies alcohol use. Denies use of Illicit drugs. Denies smoking. Reports occasional caffeine use. Family and Social History Marital Status Widower Current Living Situation Lives alone Number of Children 5 children
PMHNP Patient Intake and OSCE Soap Note
Occupation and Current Job Works in a grocery store Education Highschool education Social Support 5 children and states they are reliable support Childhood Living Situation (adults only) Raised by mother and father. Mother history MDD, father heavy alcohol use until the age of 40 Diet Unchanged diet and eats 2 - 3 times a day Physical Activity Unchanged physical activity reports never exercised Sleep Reports trouble getting to sleep and sleeps 7 hours a night. Denies difficult to wake up. Medical History Reports arthritis Neurodevelopmental History Denies abnormal development and all milestones met. Psychiatric Family History Parents Reports dad was a heavy drinker but stopped by the time he was 40 years old. Mother history of depression. Grandparents (maternal/paternal) None Siblings None Children None Psychiatric Review of Systems Depression Patient reports he sleeps 7 hours a night and has difficulty falling asleep. Reports poor concentration. He reports he has lost interest in social events such as going to church, since his wife’s passing. He reports decreased energy. Suicidal/homicidal He reports he would like to go to sleep and not wake up. When asked about suicidal thoughts, he denies plans to hurt himself saying he would never want to do that to his kids. Psychosis/Schizophrenia He reports hearing his wife’s voice at times. When asked if he believes she is there, he reports he knows she is gone and that its not really her voice. He denies seeing things that aren’t there. Generalized Anxiety Disorder Denies feeling anxious or worried. Panic attacks/panic disorder Denies panic attacks. OCD Denies compulsive behavior. Bulimia Nervosa/Anorexia/Binge Reports he eats 2 - 3 meals a day and that has not changed.
ASSESSMENT
Physical Examination Blood pressure: 121/ Heart rate: 76 (Vital Signs: Temperature, pulse, respiratory rate, and blood pressure) Respirations: 18 Height: 5’9” Weight: 167lbs Laboratory Data Blood tests: WNL EKG: WNL Diagnoses Primary Diagnosis Major Depression Disorder Secondary Diagnoses (if needed) Prolonged Grief Disorder Diagnosis Rationale Primary Diagnosis Rationale: Mr. Smith has reported feeling “down and numb” for 1.5 years since his wife’s passing. He reports he has difficulty falling asleep, poor concentration, decreased energy, and that he has lost interest in things he once enjoyed. Mr. Smith also reports that he would like to go to sleep and not wake up most nights. Though he denies a plan to hurt himself, he presents with recurrent thoughts of death which makes 5 symptoms that permit a diagnosis of a major depressive episode. Mr. Smith also mentions a family history of MDD stating his mother has depression which is significant for this diagnosis. Secondary Diagnosis rationale: Mr. Smith has been experiencing prolonged grief, greater than one year following the death of his wife. He presents with a preoccupation for the deceased, presents with emotional pain and sorrow, he mentions he believes life not being worth living, and he is having difficultly rejoining society after her passing. These are all symptoms of prolonged grief disorder. Differential Diagnoses Differential Diagnosis # Persistent Depressive Disorder Differential Diagnosis # Post-traumatic Stress Disorder Differential Diagnosis # Adjustment Disorder with depressed mood Differential Diagnosis Rationale Differential Diagnosis Rationale #1: Persistent depressive disorder presents with chronic depression with a depressed mood for most of the day and for more days than not, for at least 2 years. According to Boland (2021), symptoms tend to be less severe than Major Depressive Disorder. Mr. Smith’s symptoms could occur for 6 more months qualifying him for a potential diagnosis of PDD. Differential Diagnosis Rationale #2: According to the Diagnostic and Statistical Manual for Mental Disorders (DSM- 5 - TR, 2022), post-traumatic stress disorder is when the patient re-experiences the traumatic event and avoids reminders of
EVIDENCE-BASED PLAN OF CARE
SMART Treatment Goals (Specific, Measurable, Achievable, Realistic, Timely) Goal 1: Mr. Smith will improve his mood, reduce depressive symptoms, and decrease the frequency of intrusive thoughts (specific). He will engage in weekly therapy sessions starting with one session per week (achievable) to address depressive symptoms directly (realistic). His mood will be reassessed in 3 months (timely) by means of tracking mood improvements with a standardized depression scale, such as the PHQ-9. He will achieve a score of less than 10 on the PHQ-9 within 3 months (measurable). The objective is to monitor for the decrease in symptoms of both MDD and PGD. Goal 2: Mr. Smith will increase his social interaction by attending group grief counseling (specific). He will start by attending once a week (achievable) to combat his social isolation that has been worsening his depression (realistic). He will begin these sessions within the month and continue for 6 months (timely). His mood will be reassessed after 3 months using a 0-10 scale to assess for grief related distress with the goal of a market decrease in the score (measureable). Psychotherapeutic Treatment # Cognitive behavioral therapy Psychotherapeutic Treatment # Group grief counseling Pharmacological (Drug name [trade and generic], route, dosage, times per day, amount to be dispensed, # of refills) Sertraline (Zoloft) 25mg by mouth once a day in the morning. Dispense a 30 - day supply with no refills. Evidence-Based Treatment Plan Rationale Psychotherapeutic Treatment #1 Rationale: Cognitive behavior therapy (CBT) will be used to address the negative thought patterns and behaviors that Mr. Smith presents with. According to Wang (2016), CBT has been shown to be more beneficial for the patient with depression than the usual treatments. CBT is based on the idea that a person’s perception can change their thoughts and thus change their behavior. It is hoped that Mr. Smith will benefit from a new perception and improvement in his thoughts and mood. Psychotherapeutic Treatment #2 Rationale: Group grief counseling will be used for Mr. Smith’s treatment to address the loss of his wife as well as to provide him with a group setting with the potential for socialization. Networking for Mr. Smiths grief counseling will be through his church since he has mentioned a previous relationship with God and his church. According to Boyd (2022), grief counseling, especially in a group, can normalize the feelings of sadness and pain that comes with the loss of a loved one while also encouraging engagement with a support system. Pharmacological Treatment Rationale: Sertraline (Zoloft) is an SSRI, which is often the first-line treatment for major depressive episodes. Mr. Smith will have regular follow-up to monitor for efficacy and side effects, especially considering the elderly population can be sensitive to psychiatric medications. According to Wang (2016), the initial starting dose of sertraline for an older adult is 25mg. This is to avoid the potential for GI side effects and to promote adherence to the medication. The dose may be increased to 50mg to ensure efficacy of the medication. Refills will not be ordered until a consistent dose is established after follow up visits. Mr. Smith will be taking this medication in the morning to avoid the potential side effect of insomnia and he will report any other side effects at the next visit. the trauma and reacts with negative changes to thoughts and mood. If the death of Mr. Smith’s wife causes some trauma for Mr. Smith, PTSD should be considered. Mr. Smith also avoids social events that remind him of his wife. Differential Diagnosis Rationale #3: Adjustment disorder with depressed mood presents with emotional or behavioral symptoms in response to an identifiable stressor and those symptoms present within 3 months of the stressor, according to First (2014). For adjustment disorder with depressed mood, symptoms usually do not continue 6 months after the stressor or since the consequences have ended. In the case of Mr. Smith, the consequences of his wife’s death are still not resolved so an adjustment disorder may still be considered.
After reviewing the video of your OSCE, write a self-reflection on your performance as a nurse practitioner. After reviewing my OSCE, I have considered many areas that require improvement as well as areas I did well in. I showed the patient empathy and understanding throughout the interview, which is crucial for establishing trust and rapport with the patient. Communication was clear and respectful, and I allowed time for the patient to express himself when he became tearful. Thing I could improve on includes the areas I had missed during the interview. I would have assessed his mood while using a 0-10 scale with 0 being the worst he has ever felt and 10 being the best he has ever felt. I would have asked for more clarity regarding the conditions of his wife’s death to better understand Mr. Smith’s reasoning for such a prolonged grieving period. I would have liked to provide the patient with more information regarding their treatment and educating the patient about the kinds of therapy there is available. I would have liked to of been clearer about the follow up plan and what to do incase on a crisis. I feel that I have fell short in many of these areas and I plan to improve in the aspects of the interview in future experiences. With improvement of my interview skills, I will be ensuring improved patient outcomes and satisfaction. Different Clinical Setting What changes would be made to the patient assessment or treatment plan if the patient were in the opposite clinical setting? (For example, if the patient was seen in the outpatient seṄng would any changes occur if they were seen in the inpatient seṄng for the same diagnosis or vice versa) Follow-up Plan (Including emergency services) Schedule follow up appointments for medication management starting with biweekly and then monthly depending on progress and side effects. These appointments are to monitor progress, adjust medications as needed, and to provide ongoing support. Schedule regular appointments with psychotherapy to address emotional and psychological needs. Be aware of the warning signs of crisis such as having increased suicidal thoughts and seek medical attention immediately at your nearest emergency room.
Self-Reflection
References
Boland, R., & Verduin, M. (2021). Kaplan & Sadock's concise textbook of clinical psychiatry (5th ed.).
Wolters Kluwer Health.
Boyd, C., & Luebbert, R. (2022). Psychiatric nursing: Contemporary practice (7th ed.). Wolters
Kluwer
American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders, text
revision (DSM- 5 - TR) (5th ed.). American Psychiatric Association Publishing, Inc.
First, B. M. (2014). DSM- 5 handbook of differential diagnosis. American Psychiatric Association.
Wang, S., & Nussbaum, A. M. (2016). DSM- 5 pocket guide for elder mental health. American
Psychiatric Publishing.
