Grand Rounds Discussion: Complex Case Study Presentation

Caroline E Sam

College of Nursing-PMHNP, Walden University

PRAC 6675: Grand Rounds Discussion Complex Case Study Presentation 07/27/2022


”Attempted suicide because the voices told me to do so.”

HPI: C.P is a 55-year-old African-American male with a reported history of schizophrenia depression type that presents to the hospital for psychiatric assessment due to increased suicidal ideation and auditory hallucinations. The patient reports that one time he attempted suicide by cutting his wrist because he was hearing voices telling him to do so. C.P further reports that he has always struggled with medication compliance and in other cases, he has also had difficulty refilling his prescription due to lack of funding. He mentions being off his medications for 2 weeks. The patient further reports feeling lonely after his only sister left home for college and he was unable to take his medication refilled. He started experiencing visions and sounds that he could not understand (visual and auditory hallucinations). The patient reported experiencing poor sleep patterns. C.P further notes high levels of anxiety, depressed mood, anhedonia, low energy, and increased suicidal ideation. The patient also reports attempting to burn the family house after his sister abandoned him for college because he could not stand living there alone.

Past Psychiatric History:

· General Statement: The patient experienced his first symptoms of mental illness at the age of 26 years, was hospitalized on three occasions, and received treatment. Factors that contributed to his hospitalization include feelings of paranoia and impulsiveness regarding thoughts of harm to others and self.

· Caregivers (if applicable): None

· Hospitalizations: Hospitalized on three occasions.

· Medication trials: Depakote, Zyprexa, trazodone, Haldol, and Lithium.

· Psychotherapy or Previous Psychiatric Diagnosis: Schizophrenia

Substance Current Use and History: None

Family Psychiatric/Substance Use History: C. P’s mother had psychiatric problems and his father had alcohol and substance use issues.

Psychosocial History: The patient has never been married and has no children. He was in special education all through his primary and secondary school. She lived with his sister

NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template

Week (9): (Ground Rounds Discussion: Complex Case Study Presentation)

Judith Uwazuruonye

College of Nursing-PMHNP, Walden University

NRNP 6675: PMHNP Care Across the Lifespan II

DR Ishkova

July 27, 2022

Presentation Objectives

i. To perform a comprehensive psychiatric patient evaluation on the patient.

ii. To develop a differential diagnosis based on the subjective and objective data obtained.

iii. To determine the most reasonable diagnosis based on the patient’s symptoms.

iv. To develop a patient-centered treatment plan for the patient.


CC (chief complaint): “Anxiety on going out.”

HPI: L.L. is a 65 years old African American patient seeking help in managing anxiety. The patient admits to feeling anxiety when going to the stores and driving from her comfort zone. She struggles with overwhelming anxiety and avoidance of the anxiety. The onset of her anxiety was gradual following an incident in the early 2000s when she experienced an episode of encopresis before she could make it to the bathroom. Since the event, she has been avoiding going to stores and gradually grew anxious when driving due to the fear of getting lost and losing control. Since her retirement, the fear has increased significantly, and this has kept her away from seeing her family, going to physician appointments alone, and engaging in recreational activities. She has few friends, is widowed, and is not in a relationship. She lives with her children in a rented apartment. Her medical history is positive for irritable bowel syndrome and glaucoma. She denies a history of military service, legal issues, or drug or substance abuse. Her medication list includes Buspar 2.5mg P.O. in the evening. She was previously on Zoloft 25mg daily, but this was discontinued due to the feeling of drowsiness. She feels depressed due to the fear of leaving her house. She is allergic to Biaxin. L.L. reports not being compliant with her medications and requiring the withdrawal of the current medications.

Substance Current Use: Denies

Medical History:

· Current Medications: None

· Allergies: Biaxil. Unknown reaction

· Reproductive Hx: Post-menopausal. Has 3 children. Not sexually active. Widowed.

· Surgery: No past surgery

Family history

Mother- generalized anxiety disorder

Father- Alcohol use disorder

Children- No remarkable health issues

Social history

The patient lives in a rented apartment with her children. She is widowed and is not currently in a relationship. She is retired. She denies a history of drug or substance use, legal is

NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template

Week 9: Grand Rounds Discussion: Complex Case Study Presentation

Sherie Reed

College of Nursing-PMHNP, Walden University

NRNP 6675: PMHNP Care Across the Lifespan II

Dr. Nataliya Ishkova- Volovets

June 28, 2022


CC (chief complaint): “I’m starting to hear voices again.”


           A.B. is a 37-year-old male with a history of Schizophrenia. The client is single with no children and resides with his parents in New Jersey. He lives in the finished basement of his parent’s home that they fixed up for him. His highest level of education is two years of community college. The patient is currently unemployed and on disability for his mental health issues. The client was going to a mental health professional that retired two years ago and hasn’t seen anyone since. He participates in therapy on and off with a therapist he has been visiting since he was 25. The patient was hospitalized when he was 24, and that is when he was diagnosed with Schizophrenia. His psychiatrist prescribed him Abilify, but he hasn’t taken it in the past year and a half due to his psychiatrist retiring. The patient has reported auditory and visual hallucinations since he stops taking Abilify. His parents helped him find this facility to start a treatment regimen.


Substance Current Use: The patient denies any substance use. 

Medical History: The patient denies any medical or surgical history. 


·     Current Medications: The patient denies taking any medications. 

·     Allergies: No known drug or food allergies.

· Reproductive History: The client does not have any children. 


· GENERAL: Patient denies fevers, chills, sweats, or weight changes.

· HEENT: The patient denies any difficulty hearing and no symptoms of rhinitis or sore throat. 

· SKIN: The patient denies any rashes or skin changes. 

· CARDIOVASCULAR: The patient denies having chest pain or palpitations.

· RESPIRATORY: The patient denies dyspnea on exertion and no wheezing or cough. 

· GASTROINTESTINAL: The patient denies nausea, vomiting, diarrhea, constipation, or stomach aches.

· GENITOURINARY: The patient denies any genitourinary issues. 

· NEUROLOGICAL: The patient denies headaches, no seizures, no numbness, no tingling, and no weakness. 

· MUSCULOSKELETAL: The patient denies myalgias or arthralgias.

· HEMATOLOGIC: The patient denies having any hematologic issues. 

· LYMPHATICS: The patient denies having any lymphatic issues. 

· ENDOCRINOLOGIC: The patient denies excessive urination or excessive thirst.