Paper Example on Case Analysis Exercise - OGS

The selection of this patient encounter was based on the sensitivity of the health problem as well as the uniqueness of the patient. As captured in the SOAP note, the case was of a 59-year old male patient. The patient was addicted to alcohol and exhibited symptoms of depression. Other than alcohol, the patient also used cocaine occasionally. He was undergoing withdrawal symptoms and hence needed help. Cooperation and behavior was the practicum objective for this case. The client, therefore, offered an excellent opportunity to determine how far the objectives developed could go in helping realize the objective. All the patient's body parts were affected by his condition. The symptoms had persisted for the last six months and had graduated from mild to severe. It is also worth noting that the symptoms were on and off, especially in the mornings. As such, it was important to determine how these issues are factored into the process leading to their cooperation and behavior change. Resultantly, a medication regime consisting of psychotherapy at the individual, group, and A.A. meeting was prescribed. The treatment employed several tools, including the PHQ9 for depression, Hamilton Mood Questionnaire, the cutting down angry, guilty eye-opener (CAGE) for alcohol, and the AIMS tool for dyskinesia movements.

SOAP

Patient Description:

The patient is a 59-year-old male that came into the clinic for help with his addiction to alcohol and depression. He uses cocaine occasionally. He is currently going through withdrawal and needed something to help him.

Subjective: Symptoms: COLDSPA

Characteristics: Depression, anxiety, abdominal distention, nausea, headache, shaky hands, sweating, insomnia, vomiting, and hallucinations.

Onset: The symptoms were of gradual onset as they started mildly and then increased in intensity.

Location: The patient states that he experiences pain in every part of his body and has tremors in his hands.

Duration: The symptoms have persisted for six months.

Severity: The patient rates the severity of his symptoms at 8 out of 10.

Pattern: The symptoms are on and off mostly during the mornings.

Associated factors: Seizures, racing heart, confusion, and fever.

Course: The symptoms have been increasing for six months.

Stressors: Physical activity and cold weather.

Collateral information: Decreased appetite, smoker, low economic status, weight loss, and weakness.

Staff observations: Agitation: The patient appears agitated and restless.

Sleep log: The patient appears sleep-deprived.

Objective: Cooperation and Behavior

Review of the system:

Cardiac: Palpitations and dyspnea.

Respiratory: Difficulty in breathing

Dermatological: Skin rash

Endocrine: Remarkable

Gastrointestinal: Nausea and vomiting

Musculoskeletal: Weakness

Neurological: Seizure and headache

Hematological: Pallor and jaundice.

Diagnostic tools findings: PHQ 9 (Depression) - Positive

Mood Questionnaire, Hamilton (Anxiety) - Positive

CAGE (Alcohol) (Cutting down, angry, Guilty, Eye-Opener) - Positive

AIMS - Positive dyskinesia movements in the patient as he is being treated with antipsychotic medications.

Appearance:

Gait: abnormal gait; Posture: Unable to maintain an upright posture; Clothes: Dirty unwashed clothes; Grooming: Not well-groomed, appears unkempt; Hygiene: Lack of proper hygiene.

General behavior:

Mannerisms: Lack of manners; Gestures

Unable to use proper non-verbal communication

Psychomotor activity: Proper psychomotor activity

Expression: Slurred speech

Eye contact: present

Ability to follow commands/requests: True

Compulsions: absent.

Attitude: evasive, easily distracted

LOC: confused,

Orientation: All present (place, person, and time)

Memory: Present (immediate, recent, and remote)

Intellectual: vocabulary, fund of knowledge

MMSE: points achieved out of 30, No tasks missing

Speech:

Volume/tone - soft,

Rate- slow

Amount- poverty,

Fluency/rhythm - slurred, inflections appropriately placed, good articulation, hesitant, aphasic)

Mood (inquired):

Depressed, euphoric, euthymic, elevated, euphoric, anxious, and irritable.

Affect - flat and irritable

Thought process/form:

Goal-directed, linear, circumstantial, loose associations, tangential, incoherent, thought blocking, evasive, racing, perseveration, perseveration

Thought content:

Delusions (types involved: persecutory/paranoid, grandiose, religious, , bizarre, somatic, nihilistic, thought broadcasting, thought withdrawal, thought insertion), ideas of reference, magical thinking, illusions/hallucinations (visual, somatic, auditory, tactile, olfactory, commentary, conversation, command, gustatory), suicide/homicide (elaborate further: passive, active, hopelessness, plan, detailed plan, partially executed plan, available method , impulsivity, command hallucinations, contracting, intention), phobias (type: specific/simple, social, agoraphobia), obsessions

Insight/Judgement:

Awareness of role/problem, abstract (similarities, proverbs), comprehension of facts, draw conclusions, problem-solving

Laboratory and other tests

Assessment: Alcohol withdrawal and depression

DSM-V: Alcohol withdrawal code: F10.23

DSM-V: Depression code: F33.0

Plan:

Diagnostic:

Get collateral information, conduct further questioning or observation, screening tools, blood tests, EKG.

Specific treatment:

According to diagnosis such as, the number of ECT sessions, medication titration, etc. General treatment: reduction of stresses, modify the environment, education, symptomatic such as insomnia Counseling/therapy: CBT skills, relapse prevention, addiction counseling e. The document that you have discussed the risks and benefits of psychotropic drugs, and the patient has agreed to take them. The document specifically that you have discussed the risks of T.D., NMS, metabolic changes, and seizures, with the use of neuroleptic drugs. A document that the patient has verbalized understanding of the teaching. Document plan with the use of a control substance, including duration.

Disulfiram, Oral (Hendrickson, 2015).

Frequency: Once Daily

Duration: 3 months

Therapeutic and side effects: headache, drowsiness, metallic taste, acne, drowsiness, decreased sexual ability, vision changes, numbness, seizures,

Compliance: Adherence reduces the risk of relapse, and hence he should observe

Other treatments: Campral, naltrexone, gabapentin, and baclofen ECT with other medications

Psychotherapy: Individual therapy, group therapy, A.A. meetings

Disposition:

The next course of care, back-up plans, and follow-up.

Differential Diagnosis

According to the DSM-5 diagnostic criteria, a client must exhibit five or more symptoms in the two weeks, one of which must be either a depressed mood or loss of pleasure or interest. Based on the SOAP notes, the client showed depressed moods that fluctuated, especially during the morning hours. The client also exhibited a marked loss of interest in most of the daily activities and pleasure and showed the interest of recovering from their substance use. Third, the client's condition slowed their physical movement but increased their restlessness caused by the spasms that they felt throughout their bodies. The client had a feeling of worthlessness and guilt and exhibited a diminished capacity to concentrate. Lastly, the client showed recurrent thoughts that bordered on suicidal ideation. Therefore, it is clear that the patient has been experiencing most of the symptoms needed for the diagnosis of major depressive disorder for at least six months. The diagnostic code for major depressive disorder is F33.2 (New York State Council, 2014). However, according to DSM-5, there exist multiple forms of depressive disorders, all characterized by dysphoria and clinical manifestations that closely resemble. Thus, a differential diagnosis is required. Some of the disorders that could be responsible for the symptoms include:

Substance/Medication-Induced Depressive Disorder

In this situation, the depressive symptoms are related to the use of certain substances or drugs. For instance, a patient showing the symptoms as a result of cocaine withdrawal will be diagnosed with cocaine-induced depressive disorder. The disorder should not be diagnosed when there is a prior history of recurrent depressive episodes or in situations where the disturbance is only caused by episodes of delirium. In this particular case, the patient is addicted to alcohol and occasionally uses cocaine. He presented to the clinic with withdrawal symptoms, and hence it can be concluded that the withdrawal causes depressive symptoms. As such, the patient is suffering from a substance-induced depressive disorder. The diagnosis code for alcohol withdrawal with perceptual disturbances is F10.232, while that for cocaine withdrawal is F14.23 (New York State Council, 2014). The diagnostic code for alcohol-induced depressive disorder is F10.24, while that for cocaine-induced depressive disorder is F14.24 (New York State Council, 2014).

Mood Disorder Caused by another Medical Condition

In this situation, the patient has a pre-existing medical condition such as stroke, multiple sclerosis, or heart disease. Generally, the disturbance starts in the first month of the onset of the particular medical condition. In this specific case, the patient does not have any pre-existing medical condition. Its diagnostic code is F06.34 (New York State Council, 2014).

Persistent Depressive Disorder (Dysthymia)

According to DSM-5, the major difference between dysthymia and major depressive disorder is that the latter lasts for at least two years. For a patient to be diagnosed with dysthymia, they must have exhibited three of these symptoms for at least two years; depressed mood for most of the day, changes in appetite, changes in sleep patterns, low self-esteem, low energy, impaired concentration, as well as a sense of hopelessness. While the patient exhibits several of these symptoms, they have not persisted for at least two years. Its diagnostic code is F34.1 (New York State Council, 2014).

Attention deficit/Hyperactivity Disorder

Patients presenting with this condition are generally easily distracted and frustrated. Some of the symptoms that attention-deficit/hyperactivity disorder share with the major depressive disorder include inattention, impaired concentration, and fidgeting. However, these symptoms are pervasive in attention-deficit/ hyperactivity disorder and only prominent during active mood episodes in major depressive disorder. Moreover, some symptoms present in major depressive disorders such as disturbance in sleep and appetite, as well as suicidal thoughts, are absent in attention-deficit/hyperactivity disorder. The patient is, therefore, unlikely to be suffering from attention-deficit hyperactivity. However, it should be noted that attention-deficit hyperactivity occurs co-morbidly with depressive disorders in some instances. Its diagnostic code is F90.2 (New York State Council, 2014).

Borderline Personality Disorder

This condition can also be easily confused with major depressive disorder. Some of the shared symptoms include dysphoria as well as recurrent suicidal thoughts. However, while mood states in borderline identity disorder fluctuate within one day, major depressive disorder is characterized by the fluctuation of mood states for most of the day. Besides, borderline personality disorder also includes identity disturbance, huge efforts to avoid abandonment, as well as intense feelings of emptiness, features that are nor present in major depressive disorder.