Case Analysis Evaluation 3 Instructions
Chief complaint: â€œMy employer said I need to come.â€
HPI: Rachel is a 26 Years old black female who presents to the clinic seeking psychiatric treatment. She says was referred by the director at the daycare center where she works. Rachel feels that the director is being irrational and does not need treatment. She describes the director in negative terms, making clear that she knows more about running a daycare center than her director. Rachel states she is committed to her job and has held several positions but does not get along with others. She reports that she is easily angered and views authority figures with deep suspicion. She sees herself as flawed, broken, unloved, and unlovable. She reports suicidal thoughts when feeling down, feels lost, hopeless, and alone. She states that the only thing that helps with the experience is to inflict pain on herself. Racheal was proud to show off the old scar of superficial cuts and burns. Denies sudden weight loss, excessive sweats, hair loss, and chronic fatigue.
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Psychiatric History: Rachel has never been psychiatrically hospitalized and has never seen a psychiatric provider. She states that she did speak to her minister and college chaplain while in college for emotional issues. States’ primary care provider had prescribed fluoxetine 20mg for some time but unsure as to whether this is of any benefit. The onset of symptoms- Anxiety- â€œall my life,â€ self-mutilation, chronic feelings of emptiness started at age 18, depression â€œon and off all my life,â€ anger started around age 18.
Past Medical History: Rachel is in good physical health with no medical hospitalizations.
Surgical History: None
Family Medical History: Mother- Anxiety, HTN; died at age 53. Father- CHF; died at age 66-years. Brother- Stomach ulcer, tobacco smoker. Sister has anxiety and depression
Social History: Rachel lives alone in a rental apartment. She buys a bottle of liquor after work on some days and goes home to drink until she passes out. She will wake up in the morning some days to find herself with someone she had to pick up from the bar and whose name sheâ€s unable to recall. When asked about safe sex practices, she refused to respond. Rachel states do not have many friends because she does not get along with people in general. Denies history of tobacco use. Denies legal history.
Educational/Occupational History: Rachel completed high school and did well at school. Complete two years of college. She works full time at the daycare, unable to maintain a job over one 1year. Previous jobs include various fast food restaurants, departmental stores, customer service call centers, and daycare centers.
Developmental/Family History– Rachel is the youngest of three children. She was born and raised in a rural area in a Southern state. She describes childhood as lonely and unhappy. She states that was why she moved to the city after high school. She denies developmental problems. She did not have a good relationship with siblings and relatives. Older brother and sister are married and live in houses on the parentâ€s property. Rachel describes her parents as hardworking. She says her father had retired to work on his farm before he passed away. Her mother never worked outside the home and still works on the farm. The motherâ€s sister also lives on the same property.
Review of Systems: 10-system ROS negative except symptoms noted in HPI.
Medications: Fluoxetine 20mg po once a day
Vital Signs: BP 128/80 HR 62bpm, T 98.9F, RR 18/min Weight 150lbs without significant recent changes.
Review the above case study and complete the CAE Sections below with your assigned group members. Students should be able to apply knowledge of evidence-based psychotherapies and psychotherapeutic treatment for psychiatric mental health disorders. The CAE assignment requires at least five references in current APA format and may include the course textbook. Please see Case Analysis Grading Rubric in NURS 753 Course.
Please use the 4 listed diagnoses to answer letter B and C
A. Differential Diagnosis: :
1. Borderline Personality Disorder
2. Schizoid Personality Disorder
4. Non-suicidal self-injury (NSSI)
B. Etiology: Delineate the etiology of each of the four differential diagnoses. Include psychosocial factors and past experiences that may be contributing to current symptoms.
C. Diagnostic Screening Tools: Delineate what diagnostic screening tools would be appropriate for each of the four differential diagnoses.