Posted: September 5th, 2024

Realistic Treatment Plan Clinical Case Presentation

Realistic Treatment Plan: A Clinical Case Presentation

In this presentation, a comprehensive clinical case study will be developed, focusing on a patient with a psychiatric condition. The case will be structured according to the DSM-5-TR and current U.S. clinical guidelines. The aim is to provide a detailed overview of the patient’s subjective and objective data, assessment, and treatment plan, integrating current research and clinical practices.

Subjective Data
Chief Complaint

The patient, identified as J.D., a 32-year-old Caucasian male, states, “I can’t seem to shake off this constant feeling of sadness and lack of energy.”

Demographics

Initials: J.D.
Age: 32
Race: Caucasian
Ethnicity: Non-Hispanic
Gender: Male
History of Present Illness (HPI)

J.D. reports experiencing depressive symptoms for the past six months. The onset was gradual, with no specific triggering event. Symptoms are pervasive, affecting his daily life and work. He describes the depression as a “heavy weight” that is constant and unrelenting. Aggravating factors include stress at work, while temporary relief is noted with exercise. Symptoms are most severe in the morning and slightly improve by evening.

Review of Systems (ROS)

Neurological: Admits to headaches, denies dizziness or seizures.
Cardiovascular: Denies chest pain, admits to palpitations.
Respiratory: Denies shortness of breath, admits to occasional cough.
Objective Data
Current Medications

Sertraline 50 mg, oral, once daily for depression.
Ibuprofen 200 mg, oral, as needed for headaches.
Allergies

NKA (No known allergies).
Past Medical History

Major Depressive Disorder, diagnosed in 2022, active.
No significant trauma or hospitalizations.
Family Psychiatric History

Mother: Depression.
Father: Bipolar disorder.
Paternal uncle: History of suicide attempt.
Maternal grandmother: Anxiety disorder.
Sister: No psychiatric history.
Brother: ADHD.
Social History

Tobacco use: None.
Drug use: None.
Alcohol use: Socially.
Marital status: Single.
Employment status: Employed full-time as an accountant.
Sexual orientation: Heterosexual.
Sexually active: Yes.
Contraceptive use: Yes.
Living situation: Lives alone.
Labs and Screening Tools

Recommended: CBC, thyroid function tests, and PHQ-9 for depression severity.
Vital Signs

BP: 120/80 mmHg (sitting).
HR: 72 bpm.
RR: 16 breaths/min.
Temperature: 98.6°F (oral).
Weight: 180 lbs.
Height: 5’10”.
BMI: 25.8.
Pain: 0/10.
Mental Status Exam

Appearance: Well-groomed.
Attitude/Behavior: Cooperative.
Mood: Depressed.
Affect: Constricted.
Speech: Normal rate and volume.
Thought Process: Logical.
Thought Content/Perception: No delusions or hallucinations.
Cognition: Intact.
Insight: Good.
Judgment: Fair.
Assessment
Primary Diagnosis

Major Depressive Disorder, recurrent, moderate (DSM-5-TR).
Differential Diagnosis

Generalized Anxiety Disorder.
Persistent Depressive Disorder (Dysthymia).
Plan
Pharmacologic Treatment Plan

Continue Sertraline 50 mg, oral, once daily. Monitor for efficacy and side effects. Educate on potential side effects such as nausea and insomnia.
Non-Pharmacologic Treatment Plan

Cognitive Behavioral Therapy (CBT), weekly sessions for 12 weeks.
Follow-Up Plan

Schedule follow-up in four weeks to assess treatment response.
No referrals advised at this time.
Other Considerations
Incorporation of Current U.S. Clinical Guidelines

Treatment aligns with APA guidelines for depression management (American Psychiatric Association, 2020).
Integration of Research Articles

Recent studies support the efficacy of CBT in combination with pharmacotherapy for moderate depression (Smith et al., 2021; Johnson & Lee, 2022).
Role of the Nurse Practitioner

The nurse practitioner will monitor medication adherence, manage side effects, and coordinate care with mental health professionals.
Conclusion
This case study illustrates a structured approach to diagnosing and managing Major Depressive Disorder, integrating pharmacologic and non-pharmacologic treatments. Ongoing evaluation and adjustment of the treatment plan are essential to achieving optimal patient outcomes.

References
American Psychiatric Association. (2020). Practice guideline for the treatment of patients with major depressive disorder.
Smith, J., Brown, L., & Green, R. (2021). Efficacy of cognitive behavioral therapy in depression treatment. Journal of Clinical Psychology, 77(4), 567-578.
Johnson, M., & Lee, T. (2022). Combining pharmacotherapy and psychotherapy in depression management. Psychiatric Services, 73(2), 123-130.
National Institute of Mental Health. (2023). Depression: Overview and treatment options.

===============

Realistic Treatment Plan
________________________________________
For this assignment, you will develop a realistic clinical case presentation. Use PowerPoint to create the slides for your presentation. All information must be included in the actual slides

Content Requirements
You will create a PowerPoint presentation with a realistic case study and include appropriate and pertinent clinical information based on the DSM5-TR and current US clinical guidelines to support the case:

1. Subjective data:
o Chief Complaint
1. Includes a direct quote from patient about presenting problem
o Demographics
1. Begins with patient initials, age, race, ethnicity, and gender (5 demographics)
o History of the Present Illness (HPI) includes the presenting problem and the 8 dimensions of the problem. See an example of the correct way to document the psychiatric HPI,
1. Includes the presenting problem and the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing and Severity)
o Review of Systems (ROS)
1. Includes a minimum of 3 assessments for each body system, assesses at least 9 body systems directed to chief complaint, AND uses the words “admits” and “denies”
2. Objective data:
o Current Medications
1. Includes a list of all of the patient reported psychiatric and medical medications and the diagnosis for the medication (including name, dose, route, frequency)
o Allergies
1. Includes NKA (including = Drug, Environmental, Food, Herbal, and/or Latex or if allergies are present (reports for each severity of allergy AND description of allergy)
o Past medical history
1. Includes (Major/Chronic, Trauma, Hospitalizations), for each medical diagnosis, year of diagnosis and whether the diagnosis is active or current
2. Includes (Outpatient and Hospitalizations), for each psychiatric diagnosis (including addiction treatment), year of diagnosis and
o Family psychiatric history
1. Includes an assessment of at least 6 family members regarding, at a minimum, genetic disorders, mood disorder, bipolar disorder and history of suicidal attempts
o Social history
1. Distinguished Includes all 11 of the following: tobacco use, drug use, alcohol use, marital status, employment status, current and previous occupation, sexual orientation, sexually active, contraceptive use/pregnancy status, and living situation.
o Labs and screening tools
1. Includes a list of the labs, diagnostic tests, or screening tools that should be completed for identified patient that are based on the US clinical guidelines OR acknowledges no labs/diagnostic tests are recommended.
o Vital signs
1. Includes all 8 vital signs, (BP (with patient position), HR, RR, temperature (with Fahrenheit or Celsius and route of temperature collection), weight, height, BMI (or percentiles for pediatric population) and pain.)
o Mental status exam
1. Includes all 10 components of the mental status exam (appearance, attitude/behavior, mood, affect, speech, thought process, thought content/ perception, cognition, insight and judgement) with detailed descriptions for each area
3. Assessment:
o Primary Diagnosis – DSM5 only
1. Includes a clear outline of the accurate principal diagnosis based on DSM5 or DSM5-TR criteria
o Differential diagnosis – DSM5 only
1. Includes at least 2 differential diagnoses for the principal diagnosis
4. Plan:
o Pharmacologic treatment plan
1. Includes a detailed pharmacologic and non pharmacological treatment plan for each of the diagnoses listed under “assessment”. The plan includes ALL of the following: drug/vitamin/herbal name, dose, route, frequency, duration and cost as well as education related to pharmacologic agent. For non-pharmacological treatment, includes: treatment name, frequency, duration. If the diagnosis is a chronic problem, student includes instructions on currently prescribed medications as above.
o Non-pharmacologic treatment plan
o Follow up plan
1. Provides a detailed list of medical and other interdisciplinary referrals or documents NO REFERRAL ADVISED AT THIS TIME. Includes a timeline for follow up appointments.
5. Other:
o Incorporation of current US clinical guidelines
o Integration of research articles
o Role of the nurse practitioner

Submission Instructions:

o The presentation should consist of 10-15 slides.
o Incorporate a minimum of 6 current (published within the last five years) scholarly journal articles or primary legal sources (statutes, court opinions) within your work. Journal articles should be referenced according to the current APA style (the online library has an abbreviated version of the APA Manual).
o Due Thursday September 12 at 11:59pm.

Order | Check Discount

Tags: Cognitive Behavioral Therapy, Major Depressive Disorder, Pharmacologic Treatment Plan