PRAC 6675 Week 4 Assignment 2: Grand Rounds Discussion: Complex Case Study Presentation Paper
Objectives for the presentation:
By the end of this presentation, the learner should:
State at least five features of SUD as per the DSM-V diagnostic criteria.
Discuss two differential diagnoses for SUD.
Develop a treatment plan for a patient with SUD.
Subjective:
CC (chief complaint): “I want to quit using weed but it is becoming impossible.”
HPI:
R.D is a 26-year-old African American male who presented for psychotherapy with complaints of being unable to quit marijuana use. The client states that he wishes he would stop using marijuana. However, he states that he cannot go a day without using it. R.D started using marijuana at the age of 16 as a recreational activity, and he developed a dependence on the substance over the years. He has been on and off in individual and group psychotherapies but often gets a relapse, which makes him feel embarrassed and guilty. He becomes irritable when he goes a day without using marijuana and experiences discomforting symptoms such as anorexia, insomnia, nervousness, fine tremors, and a strong craving to smoke. These symptoms begin within 12 hours of stopping cannabis use, and as a result, he takes a puff to alleviate them and get high. However, it has become impossible due to cravings and urges. He wishes to stop using it because he often abandons important occupational and social activities to smoke marijuana and continues using it even when he knows it will put him in danger.
Substance Current Use: Currently uses marijuana. He Smokes 3-4 blunts every 3 hours.
Medical History: No history of chronic illnesses. Last Flu shot- 2 years ago; Last TT-7 years ago.
• Current Medications: None.
• Allergies: No drug/food allergies.
• Reproductive Hx: No history of STIs.
ROS:
• GENERAL: Positive for weight loss. Denies fever, chills, or malaise.
• HEENT: Denies vision changes, hearing loss, nasal discharge/blockage, hoarseness, or sore throat.
• SKIN: Denies skin color changes, rashes, or bruises.
• CARDIOVASCULAR: No palpitations, chest pain, or dyspnea.
• RESPIRATORY: No cough, wheezing, or sputum.
• GASTROINTESTINAL: Reports loss of appetite. Denies abdominal pain or bowel changes.
• GENITOURINARY: Negative for urinary symptoms.
• NEUROLOGICAL: Positive for fine tremors, nervousness, and insomnia. Denies dizziness, muscle weakness, or burning sensations.
• MUSCULOSKELETAL: No limitations in movement.
• HEMATOLOGIC: Denies bleeding or hx of anemia.
• LYMPHATICS: Denies lymph node swelling.
• ENDOCRINOLOGIC: Reports increased sweating. Denies polyuria, polydipsia, or cold/heat intolerance.
Objective:
Vital Signs: BP- 124/86; HR-110; RR-20; Temp- 98.74
Diagnostic results: Urine test- Positive for Cannabinoids.
Assessment:
Mental Status Examination:
The client is unkempt with shaggy hair and dirty nails. He is restless, nervous, and irritable. The self-reported mood is anxious, and the affect is euphoric. Speech is somewhat unclear, and the volume and rate vary from high and fast to low tones and slow. Coherent thought process. No hallucinations, delusions, or phobias were noted. He is preoccupied with thoughts of wanting to take a puff. He is oriented to person, place, and time and memory is intact. Limited attention and concentration levels. He demonstrates good abstract thought and judgment. Insight is present.
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Diagnostic Impression:
Substance Use Disorder (SUD): SUD develops due to long-term exposure to illicit substances resulting in subsequent mental and physical dependence. It may result in academic, social, and occupational impairment, alongside adverse health effects (McLellan, 2018). SUD is the most likely diagnosis based on the patient’s history of failed attempts to stop marijuana use despite the intention to stop and having an intense craving for marijuana. The use of marijuana has led to the patient being unable to fulfill his occupational and social responsibilities, and he even abandons the obligations to use cannabis. In addition, the client develops withdrawal symptoms after discontinuing marijuana use, and the symptoms are alleviated with the continuation of cannabis use (Pasha et al., 2020). The client’s presentation is characteristic of SUD.
Cannabis Withdrawal:
Cannabis withdrawal occurs following the cessation of heavy and prolonged cannabis use. It presents with three or more of the following features within about one week after cessation of heavy and prolonged use: Irritability, aggression, or anger; Nervousness/anxiety; Sleep difficulty; Reduced appetite; Weight loss; Restlessness; Depressed mood. In addition, the patient presents with at least one of the following physical symptoms abdominal pain, sweating, fever, chills, shakiness/tremors, or headache (Bahji et al., 2020). Cannabis Withdrawal is a differential diagnosis based on the patient’s symptoms of anorexia, weight loss, insomnia, nervousness, fine tremors, and sweating, which occur after staying a day without cannabis use (Bahji et al., 2020). However, the patient has not refrained from cannabis use for a week, making it an unlikely primary diagnosis.
Generalized Anxiety Disorder (GAD)
GAD manifests with persistent anxiety and worries, which are unwarranted and difficult to control. In addition, GAD presents with psychological and physical symptoms such as headaches, sleep disturbance, restlessness, muscle tension, sweating, irritability, and concentration difficulties (Ströhle et al., 2018). GAD is a differential diagnosis based on the patient’s signs and symptoms of nervousness, restlessness, sweating, and insomnia.
Treatment Plan
Psychotherapy: The client was initiated on weekly individual therapy sessions which focus on learning skills to enable him to cope with the cravings for cannabis. The client was also introduced to Group therapy to help him acquire social skills and coping mechanisms to avoid relapse (Iqbal et al., 2019).
Health promotion: Health promotion focused on lifestyle modification. The patient was guided on approaches to improve his physical and mental health and lower the risk of developing diseases, such as a healthy diet and regular physical exercises. He was also recommended to attend annual health check-ups and take Flu shots annually.
Patient Education: The patient was educated on the health, social, and economic effects of cannabis. He was educated on relaxation techniques he should use when he gets nervous such as deep breathing, meditation, and music therapy (Ströhle et al., 2018).
Follow-up: The patient was scheduled for a follow-up after four weeks to evaluate his progress with psychotherapy.
Reflection
I learned about substance-related disorders from this assignment, namely, dependence, abuse, intoxication, and withdrawal. The most common drugs abused include sedatives, opiates, stimulants, hallucinogens, and solvents (Iqbal et al., 2019). Individuals with SUD continue using the substance despite being aware of the adverse consequences. They fail to fulfill their role obligations and have legal problems. If I were to follow up with the patient, I would ask him about the psychotherapy sessions to assess if he is gaining the most from psychotherapy. I would also assess for withdrawal symptoms and cannabis-related anxiety symptoms. If I were to repeat the assessment, I would evaluate for anxiety and depressive symptoms since Depression and Anxiety disorders are common comorbidities of SUD, which often affect the recovery process (Iqbal et al., 2019).
Discussion Prompt:
i. What measures are necessary before initiating a SUD patient with any treatment?
ii. What challenges are likely to occur during psychotherapy with a patient with SUD?
iii. What are the likely health complications of SUD?
References
Bahji, A., Stephenson, C., Tyo, R., Hawken, E. R., & Seitz, D. P. (2020). Prevalence of Cannabis Withdrawal Symptoms Among People With Regular or Dependent Use of Cannabinoids: A Systematic Review and Meta-analysis. JAMA network open, 3(4), e202370. https://doi.org/10.1001/jamanetworkopen.2020.2370
Iqbal, M. N., Levin, C. J., & Levin, F. R. (2019). Treatment for Substance Use Disorder With Co-Occurring Mental Illness. Focus (American Psychiatric Publishing), 17(2), 88–97. https://doi.org/10.1176/appi.focus.20180042
McLellan, A. T. (2018). Substance Misuse and Substance use Disorders: Why do they Matter in Healthcare?. Transactions of the American Clinical and Climatological Association, 128, 112–130.
Pasha, A. K., Chowdhury, A., Sadiq, S., Fairbanks, J., & Sinha, S. (2020). Substance use disorders: diagnosis and management for hospitalists. Journal of community hospital internal medicine perspectives, 10(2), 117–126. https://doi.org/10.1080/20009666.2020.1742495
Ströhle, A., Gensichen, J., & Domschke, K. (2018). The Diagnosis and Treatment of Anxiety Disorders. Deutsches Arzteblatt international, 155(37), 611–620. https://doi.org/10.3238/arztebl.2018.0611
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Grand Rounds Discussion: Complex Case Study Presentation
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PRAC 6675 Week 4 Assignment 2: Grand Rounds Discussion: Complex Case Study Presentation Paper
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In Weeks 4, 7, and 9 of the course, you will participate in clinical discussions called grand rounds. In one of these three weeks, you will be a presenter as well as help facilitate the online discussion; in the others you will be an active discussion participant. When it is your week to present, you will create a Focused SOAP note and a short didactic (teaching) video presenting a real (but de-identified) complex patient case from your practicum experience.
You should have received an assignment from your Instructor letting you know which week of the course you are assigned to present.
To prepare:
Review this week’s Learning Resources and consider the insights they provide. Also review the Kaltura Media Uploader resource in the left-hand navigation of the classroom for help creating your self-recorded Kaltura video.
Select a child/adolescent or adult patient from your clinical experience that presents with a significant concern. Create a focused SOAP note for this patient using the template in the Resources. All SOAP notes must be signed, and each page must be initialed by your Preceptor. When you submit your SOAP note, you should include the complete SOAP note as a Word document and PDF/images of each page that is initialed and signed by your Preceptor. You must submit your SOAP Note using SafeAssign.
Please Note: Electronic signatures are not accepted. If both files are not received by the due date, Faculty will deduct points per the Walden Late Policies.
Then, based on your SOAP note of this patient, develop a video case study presentation. Take time to practice what you will say beforehand, and ensure that you have the appropriate lighting and equipment to record the presentation.
Your presentation should include objectives for your audience, at least 3 possible discussion questions/prompts for your classmates to respond to, and at least 5 scholarly resources to support your diagnostic reasoning and treatment plan.
Video assignment for this week’s presenters:
Record yourself presenting the complex case study for your clinical patient. In your presentation:
Dress professionally and present yourself in a professional manner.
Display your photo ID at the start of the video when you introduce yourself.
Ensure that you do not include any information that violates the principles of HIPAA (i.e., don’t use the patient’s name or any other identifying information).
State 3–4 objectives for the presentation that are targeted, clear, use appropriate verbs from Bloom’s taxonomy, and address what the audience will know or be able to do after viewing.
Present the full complex case study. Include chief complaint; history of present illness; any pertinent past psychiatric, substance use, medical, social, family history; most recent mental status exam; current psychiatric diagnosis including differentials that were ruled out; and plan for treatment and management.
Report normal diagnostic results as the name of the test and “normal†(rather than specific value). Abnormal results should be reported as a specific value.
Pose three questions or discussion prompts, based on your presentation, that your colleagues can respond to after viewing your video.
Be succinct in your presentation, and do not exceed 8 minutes. Specifically address the following for the patient, using your SOAP note as a guide.
Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life?
Objective: What observations did you make during the psychiatric assessment?
Assessment: Discuss their mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses and why you chose them. List them from highest priority to lowest priority. What was your primary diagnosis, and why? Describe how your primary diagnosis aligns with DSM-5 diagnostic criteria and is supported by the patient’s symptoms.
Plan: What was your plan for psychotherapy (include one health promotion activity and patient education)? What was your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.
Reflection notes: What would you do differently with this patient if you could conduct the session again? If you are able to follow up with your patient, explain whether these interventions were successful and why or why not. If you were not able to conduct a follow-up, discuss what your next intervention would be.
A note on grading:
Presenters: Review the Grand Rounds Presenter Rubric to ensure you meet the scoring criteria.
Participants: Review the Grand Rounds Participant Rubric to ensure you meet the scoring criteria.