IPR 2 - interpersonal record PDF

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Summary

interpersonal record...

Description

1

I.

Demographics/General Information (2 points) Patient’s initials: L.D.V (patient reported different name) Age: 80 Gender: F Nationality: armenian Place of residence: Bourj hammoud Marital status: widow Number of children: flower shop Occupation: used to work at flower shop Socioeconomic status: high Educational Level: university Alcohol Use 2cups/day (started since age 65 as reported by her daughter, last time

she drank 3-4 days Tobacco Use 1 packs/day Caffeine Use 2 cups/day

II.

Chief Complaint (patient’s problem or reason for visit in patient’s own words) (3 points) The patient is not able to verbalize properly. I asked frequently but patient did not respond with audible and comprehensive voices. He daughter was with her and told me that she has dementia. History of Current Illness (include current symptoms) (3 points) Patient has a history of lung cancer of 1 year and have been taking chemotherapy after doing a surgery of lobectomy. She presented for relapse and continuation of chemotherapy. the patient has dementia that started 5 years ago at the age of 75

Medical/Psychiatric History (list all patient’s admissions/treatments including dates and places) (3 points) Patient has: IPR/January 2020/Revised

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Hypertension COPD Diverticulosis Lumbosacral stenosis S/P Stroke in 2018 Psychiatric history of dementia

III.

Family History (2 points) Her daughter denied any family history of dementia or other psychiatric ilnesses Recent Losses/Stressors as Reported/Precipitating Factors (2 points) her husband died 6 years ago and her health status starts to deteriorate after this incident. " she was so strong and independent women, but everything changed since then" Her daughter also reported that the change in her lifestyle that happened at the age of 75 causing her disorder. " she used to be sportive, volunteer, worker at the flower shop, but all of a sudden everything changed after the return to Lebanon (used to live at US) at the age of 73" " she spends the day on the sofa staring at the wall. She has no interest in anything and keeps on drinking alcohol. She neither goes out, nor does activities at home

IV.

Mental Status Exam (Total: 60 points) A. Appearance (5 points) Manner of dress: appropriate dress Cleanliness: good hygiene, no bad odor Posture: patient in bed and not moving staring at the wall. Facial expressions: Neutral. She smiled at some points Identifying features (tattoos/marks/scars): None General state of health & nutrition: she doesn’t look malnutritious; she is a bit over weight. Daughter states that she eats well ( 3 times a day her normal appetite) IPR/January 2020/Revised

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Apparent age versus actual age: The patient looked old which is appropriate to her age 80. Speech (5 points) Quality: coherent

congruent

live

reliable

stammer dispirited repetitious

atypical

slurring

monotonous

spontaneous

She repeates words in Armenian and when she talks in Arabic I would not understand neither her daughter will, in a vey low voice Quantity: adequate voluminous scarce pressured patient does not talk unless you ask the question more than one time, she answers in uncomprehensible words in Armenian or arabic

Rate:

normal

Volume:

audible

slow

loud

rapid

soft

Other (specify): very low voice

B. Motor Activity (5 points) Calm-Hyperactive-Psychomotor retardation-Lethargic-Tense-TicsRestless-Rigid-Agitated

Grimaces-Tremors-Unusual gestures-

Catatonic-Fidgeting-Akathisia Describe: Patient didn’t show any signs of rigidity, hyperactivity, inappropriate reactions or gestures and She had tremulous hands.

IPR/January 2020/Revised

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C. Interaction during Interview (5 points) Interested-Relaxed-Uncomfortable-Bored-Hostile-Friendly-CooperativeSeductive-Guarded-Uncooperative-Irritable-Domineering-SubmissiveApathetic-Defensive-Suspicious Describe: patient is uncooperative but friendly and non agitated. She smiles to us sometimes

D. Mood (patient’s subjective way of explaining emotion/feelings) (5 points) Don’t know-Good-Happy-Sad-Fearful-Hopeless-Euphoric-Anxious-AngryDepressed-Irritable-Guilty-Worried-Tired-Labile-Mixed (anxious and depressed) Describe: her daughter told me that she doesn’t know what her mood is but she feels like she is becoming tired of the frequently visits to hospital.

E. Affect (patient’s display of emotion/feelings) (5 points) Euthymic-Appropriate- Constricted-Inappropriate to thought contentBlunted-Flat-Expansive-Congruent with mood-Incongruent with mood

F. Perceptions (5 points) Hallucinations:

Auditory

Visual

Tactile

Gustatory

Olfactory Illusions

Depersonalization

Hypnagogic hallucination

Derealization Describe: none reported and no signs were observed.

Thought Process (5 points) Concrete thinking

Circumstantial

Looseness of association Perseveration Derailment

Tangential Punning

Flight of ideas

Neologism

Clanging

Thought blocking Echolalia

IPR/January 2020/Revised

Word salad Racing

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Describe: the patient doesn’t talk so it was unable to be assessed. Thought Content (including suicide assessment) (5 points) Delusions:

religious

persecution

grandiose

paranoid

jealousy

Thought broadcasting Erotomania speech

somatic

Thought insertion

Ideas of reference

Thought withdrawal

Magical thinking

Poverty of

Nihilistic

Patient denied any delusional thoughts.

Obsessions/Compulsions (specify): denied any Phobias (specify): denied any.

Suicidal ideation or intent (describe past or present acts or thoughts of self harm, specific plans): denied any suicidal ideation now or in the past.

Homicidal ideation or intent (describe past or present acts or thoughts of hurting anyone.

No homicidal thoughts also G. Judgment (patient’s judgment based on hypothetical situations) (5 points) Good judgment

Poor judgment because patient cant verbalize

Describe: the patient when talking showed no signs of poor judgment and was able to talk about ethics and religion as he believe in ( trying to be faithful and should not hurt himself or others. H. Cognition (5 points) Level of consciousness Alert

Confused

Sedated

Lethargic

IPR/January 2020/Revised

Stupor

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Orientation No, stated another name

Person: Yes

No cannot be assessed patient didn’t verbalize

Place:

Yes

Time: Yes

No NA

Memory and abstract thinking Remote:

Intact

Impaired

Recent:

Intact

Impaired

Immediate:

Intact

Impaired

Confabulation No Amnesia:

Yes patient cannot remember anything from her previous

life Describe: patient has dementia and cannot remember anything, also cannot verbalize anything but muffled words in Armenian and Arabic. Level of concentration, attention and calculation Distractible:

Yes

No

Calculation NA

Diagnosis/Differential Diagnosis/Impression (10 points) The patient is suffering from: MDD Sever neurocognitive disorder due to Alzheimer

Manifested by the following MSE findings: MDD:

A. Five (or more) of the following symptoms have been present during the same 2-weekperiod and represent a change from previous functioning: at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. Partially met 1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, hopeless) or observation made by others (e.g.,appears tearful). Met (reported by daughter)

IPR/January 2020/Revised

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2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation met (reported by daughter) 3. Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day 4. Insomnia or hypersomnia nearly every day. 5. Psychomotor agitation or retardation nearly every day 6. Fatigue or loss of energy nearly every day. met 7. Feelings of worthlessness or excessive or inappropriate guilt. 8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others). 9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide. B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. met C. The episode is not attributable to the physiological effects of a substance or to another medical condition. Met Neurocognitive disorder: A. Evidence of modest cognitive decline from previous level of performance in one or more cognitive domains. (Mild decline in cognitive function/a modest impairment in cognitive performance). Met (learning/ memory domain) B. The cognitive deficits do not interfere with capacity for independence in everyday activities. Met (she can still do the ADLs) C. The cognitive deficits do not occur exclusively in the context of a delirium. D. The cognitive deficits are not better explained by another mental disorder met Alzheimer’s disease A. The criteria are met for major or mild neurocognitive disorder. met B. There is insidious onset and gradual progression of impairment in one or more cognitive domains met (for major neurocognitive disorder, at least two domains must be impaired). C. Criteria are met for either probable or possible Alzheimer’s disease as follows: For mild neurocognitive disorder:

IPR/January 2020/Revised

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-Possible Alzheimer’s disease is diagnosed if there is no evidence of a causative Alzheimer’s disease genetic mutation from either genetic testing of family history, and all the following are present: met ( Clear evidence of decline in memory and learning (met .1 ( Steady progressive, gradual decline in cognitive, without extended plateaus. (met .2 3. No evidence of mixed etiology. (met) D. The disturbance is not better explained by cerebrovascular disease, another neurodegenerative disease, the effects of a substance, or another mental, neurological, or systemic disorder. met

V.

Management (Total: 15 points) Pharmacotherapy (list drugs and attach details about each drug, including trade & generic name, classification, mechanism of action, indication for use, side effects, nursing implications) (10 points)

LORAZEPAM Classifications: benzodiazepine

Actions: Most potent of the available benzodiazepines. Effects (anxiolytic, sedative, hypnotic, and skeletal muscle relaxant) are mediated by the inhibitory neurotransmitter GABA. Action sites: thalamic, hypothalamic, and limbic levels of CNS.

Therapeutic Effects: Antianxiety agent that also causes mild suppression of REM sleep, while increasing total sleep time.

Uses: Management of anxiety disorders and for short-term relief of symptoms of anxiety. Also used for preanesthetic medication to produce sedation and to reduce anxiety and recall of events related today of surgery; for management of status epilepticus.

Contraindications: Known sensitivity to benzodiazepines; acute narrow-angle glaucoma; primary depressive disorders or psychosis; children...