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Week 4: Grand Rounds AB
Catherine Brown
College of Nursing-PMHNP, Walden University
PRAC 6675: PMHNP Care Across the Lifespan I
Professor Robert Daun
December 20, 2023
NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric
Evaluation Template
The patient is a 41-year-old male known as AB, who is facing legal issues relating to his
use of alcohol and mental illness. The first time AB presents for treatment he had
undergone 12 days in a detoxification center before refusing to attend an inpatient
treatment center, and attended only one appointment, and then failed to return for follow
up mental health care. Six weeks later AB returns, again following nine days in a
detoxification center, refusing inpatient alcohol use disorder treatment and instead
focusing on his need for mental health treatment. AB entered detoxification for alcohol
use disorder following his arrest two weeks ago for assaulting a bystander during what
he calls “a break with the time” and admits to never taking medication for mental health
concerns that he states over time have ranged from suicide attempts to depression to
“psychosis” during drinking. AB struggles to explain what exactly he means when he
says he has a psychosis while drinking but says his mind “explodes” and his body and
mind stop talking and he just reacts and is very angry “like a monster.”
AB is very clear on the fact that he has an addiction to alcohol and knows that
something is wrong with his mental health but is reluctant to explore what those
difficulties could be because he does not want to take any medicine. He also
recognizes that he is potentially in very big trouble with the law, and getting these
concerns managed before entering the formal prison system is better for his overall
health and could result in what he hopes will be a more lenient prison sentence. AB is
contrite, he recognizes he is in a serious amount of trouble and that has been caused,
ultimately, by his mental health.
Subjective:
CC (chief complaint): “I drink too much alcohol and I do not want to go to prison.”
HPI: AB, 41-year-old white male, presents to the clinic following his release from an
inpatient alcohol use detoxification center. He admitted himself to treatment following
an arrest for assault after attacking someone who had walked “too close” to him in a
parking lot, sending the victim to the hospital needing several stiches and treatment for
a concussion. Following his arrest and posting bail, he checked himself into the same
inpatient detoxification center he had utilized successfully several months prior, but
again failed to continue into an inpatient rehabilitation and mental health treatment
center. Today AB is here for an evaluation of his mental health status in the hopes that
if he can show progress on treating his mental health the court system will offer leniency
and understanding about the events that occurred. AB denies any prior legal troubles,
saying he was picked up by a school officer when he was 15 or 16 for smoking
marijuana in his car, but was never arrested up until he was 38 when he had a DUI and
crashed into a traffic light, and again when he was 41 for chasing down a female
coworker on the street when she denied his offer for a meal after work. He was also
fired.
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Since his last arrest he has remained unemployed, spending his days drinking with his
“buddies” although it is unclear how he is able to support his entertainment. In a normal
day AB stated that he drinks ten to 14 beers or eight to ten shots of liquor over the
course of several hours. When asked, AB states that he started smoking marijuana
when he was a freshman in high school but stopped in college because it slowed him
down too much even though he states he liked the way that it made him feel. AB
started experimenting with alcohol when he was a senior in high school and went to his
first house party, but it was not until he fell into a depression in college that alcohol use
increased to almost every day. AB states that he used to be able to go up to a full year
between drinks, but in recent years he has not been able to go more than a day without
drinking.
He is not very clear on where he is currently housed, he states that he has an address,
but also during the session he offers several different locations where he “stays over.”
When asked about his history, AB is avoidant when it comes to his mental health, but
states that when he was a child his parents tried to have him speak to a therapist for his
anger and impulse control issues and that he would just act out to avoid having to go.
He admits to having suicide attempts in the past but says that for several years he has
not thought about hurting himself, but that over the last year he has spent more and
more time thinking about his end. He does say that sometimes when someone makes
him mad, he wishes they would die, but he is able to hold back on those feelings, before
explaining more thoroughly the “psychosis” he says he experiences while drinking.
Calling it a break with the time and feeling like he has no control over what he is doing.
Instead, he says he is just reacting to what is happening around him, but when prodded
for further information and explanation he appears embarrassed and indicates the
desire to move on, but not before he calls himself a monster.
AB knows that he is suffering from an addiction to alcohol but is more reluctant to
discuss mental health concerns. He understands though with this current legal situation
gives him little choice but to accept that he needs to address the mental health
concerns as urgently as the alcohol use concerns. During this interview AB states that
his family has gone entirely “no contact” with him because of what he says they call his
“toxic personality,” and that he has been afraid to contact them and ask for help while
his life is spiraling out of control due to his actions. AB is reluctant to also discuss taking
medicine and states that he has refused to take medication for depression throughout
this entire life and that he heard the side effects were bad. He appreciates that it could
be good for him but admits that he is not the best at remembering and is worried about
side effects. Depression is the number one concern; he says in the past things have
been so bad that he wishes the whole world would end and is worried if he goes to jail
that will happen again. Recognizing that this is an area he is comfortable addressing
after I explain that there are lots of medication options that have tolerable side effects,
he seems open to the idea of further exploring this area.
There are times during this interview that it is difficult to follow the trajectory of his
physical and mental health over the previous two decades, at times he shares that he
was happily and gainfully employed, but this has been both preceded and followed by
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Evaluation Template
periods of unemployment and difficulty in obtaining employment. AB has never had a
driver’s license, and instead relies on acquaintances and Uber to get around when
necessary. AB is not currently receiving any type of welfare benefit or service, and
when asked if he would like to be connected with someone that would be able to help
him get those services he brushes past the question. Interestingly, AB maintains health
insurance, and he offers several family members names who could be the ones
providing his health insurance.
Substance Current Use: Alcohol, ten to 14 beers or eight to ten shots of liquor.
Medical History:
● Current Medications: None
● Allergies: Seasonal allergies
● Reproductive Hx: AB is unmarried, and has never had children.
ROS:
● GENERAL: AB appears very pale, with multiple healing bruises on his hands and
face, but otherwise in good health
● HEENT: AB has several fading bruises on his face, including a 4cm x 7cm bruise
on his cheek, a 3cm x 3cm bruise on his neck, and several bruises that look to be
about the size of a fingertip under his jaw and at his neckline.
● SKIN: AB has large bruises across the back of both his left and right hands, and
the inside of his forearms.
● CARDIOVASCULAR: ABs blood pressure is consistently higher than 135/90
indicating likely hypertension
● RESPIRATORY: WNL
● GASTROINTESTINAL: AB states that he has recently had stomachaches in the
evenings after drinking, and has lost four pounds in the previous six weeks
● GENITOURINARY: WNL
● NEUROLOGICAL: WNL
● MUSCULOSKELETAL: WNL
● HEMATOLOGIC: WNL
● LYMPHATICS: WNL
● ENDOCRINOLOGIC: WNL
Objective:
Diagnostic results: T. 98.7 P81 R23 144/93 O2 97 Ht. 5’10” Wt. 172
In addition to a full workup for the patient, he agreed to complete two depression
assessments. The Beck Depression Inventory is a 21-item assessment that can be
self-scored and has been validated for anyone between the age of 13 and 80 years old
(von Glischinski, von Brachel, & Hirschfeld, 2018). This tool is widely used in order to
appropriate diagnose depression, and with AB not convinced he might have more going
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on than just depression, this is an easy assessment that can be used to gain his trust
and develop the rapport to continue to treat all of his mental health issues (von
Glischinski, von Brachel, & Hirschfeld, 2018). The Beck Depression Inventory uses a
scale ranging from 0 to 3 and the score is found by adding up the total of all the
questions. Typically, for a patient that is healthy with no past psychiatric history a score
of 13 would indicate possible depression but for a person with a past psychiatric history,
a score of 19 or above would indicate possible depression (von Glischinski, von
Brachel, & Hirschfeld, 2018). AB completed the inventory with a score of 34, indicating
severe depression.
AB was also willing to complete the Patient Health Questionnaire (PHQ-9) which is a
short, nine-item set of questions with four possible responses – not at all, several days,
more than half the days, or nearly every day (Stanford Medicine, 2008). The questions
should be answered with a focus on the previous two weeks and how AB has felt during
the previous two weeks (Stanford Medicine, 2008). AB responded to each of the
questions, with a score of 18, indicating moderately severe depression (Stanford
Medicine, 2008). One area of concern in ABs response to the PHQ-9 is that for the final
question, “Thoughts that you would be better off dead, or of hurting yourself,” AB
responded with “nearly every day” indicating that his mental health is more severely at
risk than previously thought during the initial patient interview (Stanford Medicine, 2008,
n.p.).
Assessment:
Mental Status Examination: AB is a 41-year-year old white male presenting to the office
for mental health and alcohol use disorder treatment and management of care. He
presents in a pair of ripped jeans, a long-sleeve tee shirt, and a pair of worn
Birkenstocks. It is not apparent that he is caring for his overall hygiene, his hands are
dirty, he has not shaved in several days, his hair does not appear to have been recently
washed and looks to be greasy and clumpy, and while his face, neck, and hands/arms
are bruised he also looks as though he has not showered in several days. AB looks very
pale, but he says this isn’t too unusual for him when he is not well, and he does not
recall when his last shower was, but it was sometime during his nine days at the
detoxification center.
AB is seated in a chair, when we enter the room, he shakes my hand firmly, and is very
respectful in his manner. While sitting both of his legs are bouncing, he seems to be
maintaining a steady quick rhythm. Along with bouncing his legs he also appears to be
chewing on his gums, and he picks at his fingers when the questions become
uncomfortable for him, particularly when discussing his mental health. There are no
apparent tics or tremors. ABs speech is organized, and he speaks in a normal tone at a
normal sound. He does raise his voice when he starts to get upset when speaking
about his mental health beyond depression and he does not stutter or stammer while
speaking. AB is generally cooperative, when speaking about his reliance on alcohol
over the last several years and become more evasive in his attitude when asked
questions about mental health and past mental health experiences.
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ABs affect is generally appropriate for the situation, he is contrite about the harm he
caused to the victim he attacked in a parking lot and understands that he deserves to go
to prison, even though he is really hoping to avoid that. His mood also seems
appropriate for the situation, he seems sad and frustrated with his situation, but also has
remorse about the harm that he caused. There are moments when he mood elevates
and become angry but when the topic that caused the upset is diverted to another topic
he regains his composure and his mood returns to its’ previous state. AB speaks in a
way that is logical, he is mostly coherent, there are times when he was explaining his
medical history that it became difficult to follow along. There are times when AB
provides details that are not relevant to his history and experiences, which made parts
of the patient interview challenging, but he was able to recover and return to a more
coherent thought process. AB is oriented to person, place, and time.
Diagnostic Impression: AB recognizes that he has been suffering from depression off
and on since he was a teenager but has never allowed himself to receive treatment for
it. AB meets the criteria for Major Depressive Disorder (F33.2) and is willing to receive
treatment so long as a medication can be found that does not cause bad side effects.
The diagnostic criteria for major depressive disorder and the symptoms that AB has that
meets this diagnosis are as follows:
● Criterion A: there must be at least five of the following nine symptoms present
during a two-week period (APA, 2022):
o Depressed mood more often than not during the previous two weeks
(APA, 2022)
▪ AB states that he feels depressed and hopeless most days and has
felt this way more often than not during the last year.
o A loss of interest or pleasure in activities that the person used to enjoy
(APA, 2022)
▪ During the patient interview AB talks about hobbies and
employment that he used to have, but now his days are spent alone
or with a small circle of people that he drinks with.
o Weight loss or gain without trying to gain or lose weight (APA, 2022)
▪ While AB has lost four pounds during the previous six weeks, that
does not equal five percent of his body weight loss during a month.
o Insomnia or hypersomnia most days (APA, 2022)
▪ Through the interview it is understood that AB struggles with falling
asleep, often relying on alcohol to help with falling asleep. AB
states that he does not takes sleeping pills or other medicine
because he knows they don’t mix with alcohol.
o Psychomotor agitation or retardation almost every day (APA, 2022)
▪ AB, when asked, agrees that he often feels restless, like he is
supposed to be doing something else, but he does not know what.
o Fatigue or loss of energy most days (APA, 2022)
▪ ABs interview uncovers his general feeling of being tired, although
he attributes it to him being tired of the way he is living his life.
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●
●
●
●
o Feeling worthless most days (APA, 2022)
▪ One of the first things AB says during the initial patient interview is
that he is a waste of space and that he knows he is a waste of
space, indicating his own perception of being worthless.
o Diminished ability to think, concentrate, or make decisions nearly every
day (APA, 2022)
▪ During the interview it appears that AB is able to think and
concentrate, but he explains he is a different person while drinking,
and that he has “really bad” ADD, but has never treated it,
seemingly writing off any challenge he might have with paying
attention or thinking.
o Recurrent thoughts of death, suicidal ideation, with or without a plan, or a
suicide attempt (APA, 2022)
▪ AB is very open about his past attempts at suicide and his many
years spent thinking about his death and what it would look like if
he were to do it to himself.
Criterion B: the symptoms that are present cause a significant amount of distress
in critical areas of life such as employment and social areas (APA, 2022).
o Due to ABs behavior during this period, he is no longer employed, he has
a very small circle of people he associated with, and he shares he is no
longer welcome at home with his family.
Criterion C: the symptoms are not because of another medical condition or of a
substance (APA, 2022)
o AB states several times during the initial interview that he has experienced
long periods of depression even when he has not been drinking, but this
most recent period of depression has been paired with an intense period
of alcohol use and abuse.
Criterion D: at least one of the previous major depressive episodes are not more
accurately understood as schizoaffective disorder or schizophrenia,
schizophreniform disorder, delusional disorder, or other specified or specified
schizophrenia spectrum or other psychotic disorder (APA, 2022)
o AB does meet this criterion as his symptoms are not better understood as
these diagnoses.
Criterion E: there has never been a hypomanic or manic episode (APA, 2022,
n.p.)
o From the information provided by AB there does not appear to have been
a hypomanic or manic episode. Initial I believed it was possible that his
violent behavior when he says that he explodes and acts like a monster
could have met the criteria for a hypomanic episode, but the behavior isn’t
overactive or high energy.
In addition to depression, it is apparent that AB is also suffering from Alcohol Use
Disorder Severe (F.10.21). AB has been relying on alcohol off and on for two decades
and in recent years it has taken over his life. The following are the required criteria and
the symptoms of alcohol use disorder that AB exhibits:
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● Criterion A: the alcohol use has resulted in there being a clinically significant
impairment with at least two of the following nine symptoms (APA, 2022)
o More alcohol is used than intended (APA, 2022)
▪ AB, through the interview, states that most days he only intends to
have a drink or two, or to just have a few drinks in the afternoon
with friends, but this then turns into several drinks most days.
o There is a desire to stop, cut down, or control the alcohol use (APA, 2022)
▪ As previously stated, AB often intends to only have a few drinks,
understanding that he is drinking a substantial amount of alcohol.
o There is a desire or failed attempts to get, use, or recover from the effects
of alcohol (APA, 2022)
▪ AB does not indicate how he obtains the alcohol that he uses, but
he does say that he is now getting stomachaches from his use of
alcohol during the day, increasing the time he needs to recover
from its effects.
o A strong desire or craving to use alcohol (APA, 2022)
▪ ABs inability to go more than a day without drinking indicates that
he has a strong urge to utilize the substance.
o Alcohol use results in their ability to fulfill obligations at work or at school
(APA, 2022)
▪ ABs alcohol use led him to treat a female coworker inappropriately,
to the point where he chased her down the street in frustration,
leading to his termination and current unemployment status.
o Continues to use alcohol even when there are social or interpersonal
issues caused by the use (APA, 2022)
▪ AB has been cut off from all contact with his family due to his
alcohol use and the violent outbursts he has while drinking, while
he is no longer employed, and apparently no longer employable.
o Important activities are given up because of the alcohol use (APA, 2022)
▪ AB has entirely withdrawn from his life, it is unclear where exactly
he resides, with who he resides, and how he is supporting his
alcohol habit. What is clear is that AB no longer is engaged in the
activities his employment offered and has been forced into a no
contact situation with his family, excluding him from those activities.
o Recurrent use of alcohol in physically dangerous situations (APA, 2022)
▪ AB is adamant that after his DUI he never again drank and then
operated a motor vehicle.
o Alcohol use is continued even when there is a physical or psychological
problem that is cause by, or made worse by, the use of alcohol (APA,
2022)
▪ ABs blood pressure and his depression are both possible effects of
his alcohol use.
o Tolerance, either the need to use more alcohol to obtain the intended
effect or using the same amount of alcohol results in a diminished effect
(APA, 2022)
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▪
AB does not explicitly state that he needs to use more alcohol for
the same effect, but he does mention during different times in the
interview that he used to only drive four or five drinks a day, and
now this has increased significantly.
o Withdrawal either with typical symptoms of withdrawal from alcohol or the
use of alcohol to stop or avoid withdrawal symptoms (APA, 2022)
▪ AB was just discharged from an alcohol detoxification center in
order to address the withdrawal symptoms that he experiences
when he previously tried to stop drinking.
A possible third diagnosis that AB could be suffering from is Intermittent Explosive
Disorder (F63.8). During the interview he makes several references to exploding like a
monster and feeling like his brain and his body are cut off from each other, acting
aggressively towards others. The following are the criteria for intermittent explosive
disorder and an explanation of the criteria that AB meets:
● Criterion A: there are recurrent behavioral outbursts that cannot be controlled
and are either verbal/physical three or more times a week over a period of three
months or there are three outbursts that result in damage to property or physical
attacks during a one-year period (APA, 2022)
o AB states that during the previous year he not only assaulted the stranger
in the parking lot, but he got into physical altercations with those that he
drinks with.
● Criterion B: the severity of the aggressive outburst is not proportionate to the
provocation or stressor that caused it (APA, 2022)
o ABs violent reactions are grossly disproportionate to the catalyst for the
behavior; the person he assaulted in the parking lot he attacked because
he was walking too close to AB.
● Criterion C: the aggressive behavior is impulsive or anger-based and not to get
money, power, or to intimidate (APA, 2022)
o ABs violent and angry outbursts are an impulse-control problem and not
an attempt to use anger or violence to get money or power or to intimidate
others.
● Criterion D: the outbursts cause distress or impairment in workplace or
interpersonal functioning, or they result in financial or legal consequences (APA,
2022)
o So far, due to his outbursts, AB has lost a job and been arrested, in
addition to being cut off from all contact with his family.
● Criterion E: the chronological age is more than six (APA, 2022)
o AB is 41 years old, so he meets this criterion.
● Criterion F: The aggressive outbursts are not better explained away by another
mental disorder or another medical condition or due to a substance (APA, 2022)
o It is likely that ABs aggressive behavior is due to his use of alcohol, but he
does make statements during the interview that he has had difficulty
controlling the monster in him since he was a teenager, before he was
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abusing alcohol. To make an appropriate diagnosis, more exploration by
someone better trained in diagnosing intermittent explosive disorder to
ensure accurate diagnosis.
Reflections: This was a patient that initially I was afraid of causing more harm to due to
his lack of trust in the mental health field, In discussing with my preceptor it became
clear that the most important part of this case was going to be showing AB empathy and
understanding of his fears about getting mental health treatment. My preceptor
reminded me to meet the patient where he is, instead of trying to bring him to where I
am in terms of wanting to care and treat for a patient. I wish I would have thought to
ask more questions about his teenage years to gain a better understanding of why he
did everything he could to not see the mental health professionals his parents located
for him. By having a better understanding of what his fears are about our profession it
would be easier to help alleviate those fears. When it seemed like he was receptive to
speaking about his experience with depression I took that as an opportunity to meet him
where he is and when he told me his fear was the side effects of the medication, I let
him know that today there are many different medications available, and if he is willing
to be patient, it is possible to find a medication that has side effects that are tolerable.
During the next follow up appointment I intend to first talk about his depression and the
prescription for Lexapro that was given to him at his first appointment. I would ask what
side effects, if any, is he experiencing. One instruction I gave him was to take the
Lexapro at night because tiredness is a side effect I see most often, but when taken at
night that side effect isn’t as frustrating to deal with as when taken in the morning.
Based upon his experience with his new prescription either increasing the dose or
staying stead at 15mg/day and then following up again in a week to continue his
treatment. During the next appointment I also intend to try and gain his trust even
further and try and better understand the anger issue that led to the behavior that
resulted in his arrest. One area of concern I spoke with my preceptor about is his belief
that by seeking treatment and staying free from alcohol means that he will be able to
avoid prison. It was hard to tell him during the first appointment that it is just not
possible to know how a judge will respond, but by being able to show the judge the hard
work he has done, that can show that changes are being made to prevent the same bad
behavior from occurring again. The reality is he severely injured an innocent bystander
and it would be unethical to tell him a lie that could keep him returning to the office but
leave him shocked when faced with the judge and sentenced to jail.
Case Formulation and Treatment Plan:
● To continue to attend AA meetings daily and attend all follow up appointments at
the detoxification center to remain free from alcohol use.
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● Return to the office weekly for treatment and follow up care for the mental health
concerns.
o Including a scheduled meeting with a social worker to discuss possible
housing and community support opportunities to encourage stability and
sobriety.
o Participate in psychotherapy opportunities at the office location with the
hope of breaking down the trust barrier and improving the patient’s
functioning by reducing the harm mental illness is causing.
● Lexapro 15mg/day
o Patient education about possible side effects
o Informed patient that taking at night can avoid a common side effect of
fatigue.
● Provided educational information about medicated assisted treatment for alcohol
detoxification and abstention to encourage continued sobriety.
● Provided copies of all consent forms signed, including the patient’s rights and
responsibilities and expectations from treatment.
● The patient has been provided information about the value of meditation and
yoga and has been provided information about the weekly guided meditation
session held at a local community center and access to free yoga at a local
senior center.
● Social determinate of health
o One social determinate of health that affect this patient is economic
stability. AB is not currently employed, and his housing status is
questionable. One target is increasing employment in working aged
people, and while there is currently little or no detectable change from the
research and work the federal government is doing, at the local level we
are able to help those in our community with much more ease (Office of
Disease Prevention, n.d.).
o There are several referrals that will assist this patient in meeting his need
for economic stability including a meeting arranged with a social worker to
identify housing and other supports that might be available.
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PRECEPTOR VERFICIATION:
I confirm the patient used for this assignment is a patient that was seen and managed by the student at
their Meditrek approved clinical site during this quarter course of learning.
Preceptor signature: ________________________________________________________
123
Date: ________________________
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References
APA. (2022). Diagnostic and Statistical Manual of Mental Disorders 5th ed text revision.
American Psychological Association: Washington, DC.
Office of Disease Prevention and Health Promotion. (n.d.). Social determinates of
health: Healthy people 2030. U.S. Department of Health and Human Services.
https://health.gov/healthypeople/priority-areas/social-determinants-health
Stanford Medicine. (2008). Patient health questionnaire (PHQ-9). Stanford University
Medical School.
https://med.stanford.edu/fastlab/research/imapp/msrs/_jcr_content/main/accordion/acco
rdion_content3/download_256324296/file.res/PHQ9%20id%20date%2008.03.pdf
von Glischinski, M., von Brachel, R., & Hirschfeld, G. (2018, November 19). How
depressed is “depressed”? A systematic review and diagnostic meta-analysis of optimal
cut points for the Beck Depression Inventory revised (BDI-II). Quality of Life Research,
28(2019): 1111-1118. https://doi.org/ https://doi.org/10.1007/s11136-018-2050-x
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