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5 pages/≈1375 words
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APA
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Health, Medicine, Nursing
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English (U.S.)
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Topic:

Case Analysis for Patient With Alcohol Use Disorder

Coursework Instructions:

Module 5: Assignment 1 (Case Analysis - Individual Adult submission) 

Please make a note that:  PSYCHIATRIC MENTAL HEALTH NURSE PRACTITIONER( PMHNP)

1.  Case Analysis Individual.Select a case from your clinical experience.  Use this experience to complete your case study assignment.  Try to select a patient that you have seen a few times in order to gather adequate data. This can be done on an Adult, Adolescent or Child.   PSYCHIATRIC MENTAL HEALTH NURSE PRACTITIONER (PMHNP)
2. ALSO, Post your case study to Module 5 for discussion. Respond to 2 classmates case study  RubricCase Study Grading RubricCase Study Grading RubricCriteria Ratings Pts
Summary and Background InformationExpected criteria: - All relevant biographical information is clearly stated and accurate.- Biographical information discusses a wide range of areas of the character's life including family, education, social support, financial status, and anything else that seems pertinent to providing care.- Identifying data and chief complaint (CC).- Family and Personal History- Genogram included.- Medical, Social and Occupational History 20 ptsFull Marks 0 ptsNo Marks 20 pts
Clinically significant HistoryAccurately identifies clinically significant symptoms for this client. - All symptoms the character is experiencing are stated and clearly explained with ample examples. Past psychiatric Hx, and History of present illness with a TIMELINE. 20 ptsFull Marks 0 ptsNo Marks 20 pts
Outcome Symptoms & Diagnosis- Psychiatric ROS, Mental Status Exam, Impression/case formulation, Dx including R/O & H/O- Symptoms are organized meaningfully into diagnoses. Symptoms that do not fall into diagnoses are explained as subclinical and what relevant diagnoses they could be classified under- A diagnosis is present, with all relevant codes and formatting, including psychosocial factors, medical factors, and cross-cutting symptoms.-Appropriate assessment tools for further investigation are accurately identified. 20 ptsFull Marks 0 ptsNo Marks 20 pts
Treatment Plan and Recommendations- Included in the plan: a) Psychopharmacology; b) psychotherapy; c) safety/Care Needs; d) Family Needs; e) Group; f) Community; g) Occupational; h) Agency; i) Referral and j) Follow-up visit-Includes measurable l/t goals and s/t objectives relevant to the problem-Includes interventions used that are relevant to the s/t objectives and treatment recommendations within the continuum of care that are appropriate to the severity of the client's symptoms. Include what type of therapy will best fit the client and ample detail about the therapy selected.-Include if medication management is also indicated. If medication is suggested, include medication name, dose, and frequency. Discuss special considerations for any special population (i.e., Geriatric, pediatric, substance misuse, individuals living with schizophrenia) 30 ptsFull Marks 0 ptsNo Marks 30 pts
Strengths/needsA thorough assessment of the strengths/needs of the client, family, peers, school, and community, MUST include relevant socio-cultural factors and developmental/environmental factors. 5 ptsFull Marks 0 ptsNo Marks 5 pts
Grammar, References, Punctuation & Spelling, Format- Rules of grammar, usage, and punctuation are followed; spelling is correct.- Language is clear and precise; sentences display consistently robust and varied structure.- Professional language is used throughout the paper.- Paper and references are in APA format, following all guidelines for structure, format, font, margins, and spacing.-Format case study with key subheadings (i.e., Summary and Background Information)-no more than five (5) pages not including the title page and references.-Must include references 5 ptsFull Marks 0 ptsNo Marks 5 ptsTotal Points: 100

Coursework Sample Content Preview:

Case Study Analysis
Institutional Affiliation
Course Code and Title
Instructor’s Name
Date
Summary and Background Information
Patient X, a 30-year-old Indian American man, has been having several episodes of alcohol use that have been affecting his daily life. He was born and raised in California by both of his parents. He is an accountant at a local bank and is required to attend work daily from 8 am to 4 pm. However, he faces the risk of termination following his prolonged absenteeism and being drunk in the workplace. Despite this, he continues drinking alcohol at the slightest convenience. He is married, and they have two children under five years old. He is a university graduate and earns a reasonable and sustainable salary. However, he is almost always financially broke since most funds go to alcohol purchases. His mother reported that she is worried that her son is turning out like his dad, who died three years ago from liver cirrhosis following years of alcohol abuse.
Chief Complaint (CC): The patient is concerned about his alcohol use behavior. He is worried that it might completely ruin his career and family. He has tried to stop, but the addiction worsens daily. His free time is always spent with friends at alcohol-selling joints.
Family and personal history: The patient has a family history of alcohol use disorder that took his father’s life. As a child, he witnessed his father wallow in alcoholism, which made him think of it as ‘okay.’ He tried his first alcohol consumption attempt at ten years when he stole his father’s alcoholic drinks, which he continued until he joined a boarding school at fourteen years.
Medical, Social, and Occupational History: The patient has been under management for acute pancreatitis, during which he was strongly advised to stop taking alcohol gradually. Following the ordeal, he started successful therapy, but he later relapsed a few months after the therapist declared him healed. He has a few friends who are all male, and they take alcohol together. He has been in five companies since he started working, and in all those places, he was terminated following inappropriate behavior due to alcoholism and fraud.
-6350298450Father0Father1104900196850Mother00MotherGenogram
19748501379220SiblingSibling2082800116967012827001366520Patient X0Patient X153035011823706159501252220Sibling0Sibling8191501663700031115011696703238501176020-508001347470SiblingSibling60960017907000
2540000220345-6350296545
12065006350
Male Female Male Alcoholic
Clinically Significant History
History of Present Illness: The patient presents to the clinic with symptoms of alcohol addiction and dependency. He appears weak, distressed, and malnourished and has been this way for the past week. His eyes are red, and his hands are shaking involuntarily. He speaks in a shaky voice. He expresses guilt in his unsuccessful attempts to quit alcoholism since he started therapy six months ago. He explains that he usually experiences a very strong urge to drink just before he engages in it.
Past Psychiatric History
General Statement: The patient has been battling alcoholism for ten years now. He has been on treatment for alcohol-related acute pancre...
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