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Clinical Case Presentation Template Psychology

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Clinical Case Presentation

Transcript: Past Medical History Chief complaint: Labs Clinical Case Presentation Case Presentation Physical Exam HPI: S.F. is a 5 week old otherwise healthy infant. Choking episode PEDS 7501 Logo

Clinical Case Presentation

Transcript: Treatment Details (cont.) 1. Non surgical root canal treatment, post and core, and crown. 2. Non surgical RCT, core, and crown. 3. Non surgical RCT and composite class V restoration. After assessing the remaining tooth structures. Nature of Pain: Pain started two weeks ago Spontaneous continuous pain Increases by cold stimulus and at night Disturbed sleep Sharp, Burning pain Pain diffuses to the left ear and left eye. Patient is taking Paracetamol ( 2 tablets 500 mg / qid. Multiple remaining roots due to caries (long time ago - Pt didn't recall). Number of visits Local anesthetic agent, amount, technique Rubber dam clamp used Number of canals Coronal flaring Working length: Reference point Measurement Initial file size Use of Electronic Apex Locators Diagnostic WL radiograph Instrumentation technique (N) Normal response (+) Mild (++) Moderate (+++) hypersensitive response (0) no response (D) delayed P.S. note: All anatomical structures are within normal limits No facial swelling No soft tissue inflammation Endodontic Diagnosis MAF size: size 40 Last step-back file size: size 80 Name, concentration, and volume of irrigant used: 3 ml of 2.6% NaOCl sodium hypochlorite. Treatment Details (cont.) No sinus tract No swelling No tooth discoloration Deep caries extends about half of the crown of #23 facially. Clinical Case Presentation Extra-Oral Examination Treatment Option Medication Pulpal diagnosis #23: Symptomatic irreversible pulpitis Periapical diagnosis #23: Normal periapical tissues Treatment Details Symptomatic irreversible pulpitis with normal periapical tissues Temperature: 37 °C Pulse rate: 86 beats per minute Pulse Rhythm: Regular Respiration rate: 18 breaths per minute Blood pressure: 125/75 mm Hg Previous dental treatment: Multiple extractions Restorations Multiple RCTs Crowns The photos were taken after the treatment of tooth #23 It was emergency treatment Medical History Working length: Reference point: Cusp tip Measurement: 28.5 mm Initial file size: 15 Electronic Apex Locator was used to determine the apical constriction Vital Signs Radiographic findings: Normal lamina dura Deep caries No PA radiolucency No PA radiopacity No dilaceration Not calcified canal Atorvastatin Aspirin Lisinopril Metoprolol Plavix insulin injection Local anesthetic agent, amount, technique: Lidocaine hydrochloride 2% epinephrine 1:80,000 2 carpules 2/3 of the 1st carpule --> Buccal infiltration 1/3 of the 1st carpule --> infiltration of the greater palatine nerve (palatal injection). 2nd carpule was used during giving intra-pulpal injection. " I have pain in my left upper side and I have multiple remaining roots that need to be extracted " Endodontic and Restorative Treatment Plan of The Involved Tooth Last dental visit: 25/7/2016 Intra-Oral Examination Rubber dam clamp used: Anterior clamp #9 (RDCM9) Isolate tooth #23. Number of canals: Single canal Coronal flaring: Endo-z bur Gates glidden #3 and #2 Number of visits: One single visit Date case started and finished: 30/10/2016 Thank you Intermediate radiograph Intra-Oral Examination (cont.) Treatment Details (cont.) Treatment Details (cont.) Treatment Details (cont.) ENDD 512 Prepared by : 33 08 01 505 MAF size Last step-back file size Name, concentration, and volume of irrigant used. Obturation: Master cone size Diagnostic master cone radiograph Obturation technique Spreader size used Accessory cone size Type of sealer Coronal restoration Final radiograph Instrumentation technique Balanced force technique Step-back technique Recapitulation with k-file size 10 Use irrigation NaOCl and EDTA Gender: Male Age: 55 years old Nationality: Saudi Marital Status: Married Level of Education: High school diploma Occupation: Retired Attitude: Cooperative Patient Data Q & A Obturation: Master cone size: size 40 Obturation technique: Lateral compaction Spreader size used: Finger spreader size F,MF,FF Accessory cone size: Fine and medium fine Type of sealer: Epoxy resin AH 26 Diagnostic master cone radiograph Endodontic Examination Diagnostic WL radiograph Dental History The prognosis of tooth #23 is favorable Reason for last dental visit: Temporary crown for tooth #11 Diagnostic Preoperative Periapical Radiograph History of Present Condition Tooth of interest : Tooth #23 Treatment Details (cont.) Treatment Details (cont.) Coronal restoration: cavit + GIC ( double seal restoration) Final radiograph Patient Medical History Chief Complaint Diabetes type II Myocardial infarction 1 year and 5 months ago Coronary artery stents Cardiac catheterization surgery Smoker RCT Post and core ? Crown lengthening ? All ceramic crown ASA III

CLINICAL CASE PRESENTATION

Transcript: PLAN/GOALS OF TX Fix cause IMMEDIATE TRANSFER TO ST VINCENTS + Large parietal/occipital extradural bleed with midline shift +Midline shift >1cm and brainstem distortion on CTB are findings that require rapid and aggressive treatment Whats wrong with this picture??? PSYCHOSOCIAL/ FAMILY: PATHOPHYSIOLOGY of EXTRADURAL BLEED Assessment- interprate this ECG Cameron, P,. Jelinek, G., Kelly, A., Murray, L. & Brown A,F, T. (2009) Textbook of Adult Emergency Medicine 3rd edition. Sydney: Churchill Livingstone Elsevier Chauvet, D., Reina, V., Clarencon, F., Bitar, A. & Cornu, P. (2013) Conservative Management of Large Occipital Extradural Haematoma. British Jounral of Neurosurgery, 27 (4), 526-528. Nadig, A, S. & King, A. T. (2012) Traumatic extradural haematoma revealed after collateral decompressive craniectomy. British Journal of Neurosurgery, 26(6), 877-879. Urden, L, D., Stacy, K, M. & Lough, M. E. (2014) Critical Care Nursing: Diagnosis and Management. St Louis, Missouri: Elsevier CTB results...... MORPHINE - sedation/analgesia Clinical Case Presentation - Ms Jones Traumatic Brain Injury MIDAZOLAM - sedation MANNITOL ACTION: GABA receptor agonist, chloride channel activation Advantages:- rapid onset/offset, reduces ICP, raises seizure threshold, less hypotensive than propofol +highly lipid soluable, + metabolised by liver Disadvantages:- can reduce MAP, delirium, withdrawl syndrome, resp & cough supression Dosage: induction 0.1/kg Maintenance sedation 0.01-0.2/kg/hr Pharmcokinetics : onset 6min, hepatically metabolised, Advantages: long term analgesic, hyponotic agent, low cost, haemodynamic stability Disadvantages: hypotension, bradycardias,respiratory & cough depression, constipation, nausea, Doseage : 0.05-0.1mg/kg Given as infusion Morph50mg/Midaz 50mg in 50ml Action: osmotic diuretic, elevates blood plasma osmolarity, thereby enhacing excretion of water from tissues as a result cerebral odema, elevated ICP is reduced Advantages:Reduces acutely raised ICP and cerebral oedema in critical care. Disadvantages:- fluid overload, rebound cerebral oedema Dosage: 0.05-0.1/kg PATHOPHYSIOLOGY of EXTRADURAL BLEED Sinus bradycardia 42 BPM flatterned T waves in LI,II &III & V5 &V6 +Maintenance of airway +Maintenance of cerebral pressures +Correct hypotension (systolic >90mmHg ) & hypoxia (PaoO2 > 60mmHg ) + sedation & analgesia - Morph/midaz + 30 degrees head up to < ICP +immediate transfer to St Vincents Hospital for Neurosurgery Patient Presentation Intubation Stabilise patient :- stabilise airway NPA, prepare for intubation. RSI- Fluid preload, Prop 40mg , Midaz 5mg and Suxamethonium 100mg IV to sedate and intubate. Adequate sedation and analgesia infusion-Morph/midaz CTB Maintain pt at 30 degree angle Maintain O2 and perfusion for cerebral blood flow NGT CXR Nursing and medical mangement TIME IS BRAIN Intubated size 7.5 ETT 22cm at lips SIMV volume control Vt 500, RR 2o, Fio2 100% Peep 5cm H2o, ETCo2 42 on monitor Morphine/Midaz infusion commenced Propofol boluses for aggitation Taken to CTB + Serous & uncommon complication of head injury + Occurs in only 3% of TBI, 75% in skull fractures + Injury to blood vessel causing formation of haematoma by stripping the dura mater from the skull +It is important to remember to involve the family, communicate honestly and effectively +Ensure adequate supports in place. + Involve care-co +If care-co not avail provide couseling to immediate family when appropriate +46 YO Female was BIBA after witnessed fall at a wedding. +Headstrike & lac to occiput +Nil LOC or seizure activity. +6-7 ETOH drinks on board + Recently fit and well +Past medical hx - C section +Medications- NIL +NKDA + 200mg IN Fentanyl, 10mg IV Maxalon on route via IVC R) hand Setting the scene + Maintenance of adequate tissue metabolism via ensuring delivery of oxygen, fuels to meet cellular demand. Cerebral perfusion pressure (CPP) Mean arterial pressure (MAP) Intracranial pressure (ICP) Cerebral Blood Flow MAP-ICP= CPP PRIMARY SURVEY A- Obstructed, requiring jaw thrust & suction of vomit, NPA insitu B- Spont resps requiring BVM, laboured breathing, Sp02 ?94% C- PW slight diaphretic, HR 40-70 SB-SR with pauses, bilat IVC, stat fluids, manual BP 150 systole D- uneven pupils, GCS4, decerebrate posturing E- C spine precautions, lac to occiput ASSESSMENT Stages of compensation & decompensation in intracranial hypertension Cushing's reflex/ triad +The presence of HTN, bradycardia and abnormal respirations associated with increased intracranial pressure (ICP) +Late finding +Sympathetic nervous system is activated = peripheral vasoconstriction, inc in cardiac output to inc MAP MAP> ICP = restored blood flow +Baroreceptors in carotid bodies detect high pressures and respond by dramatically reducing HR. Setting the scene + Initally GCS 14-15 E3V5M6 + Haemodynamically stable + During AV handover pt rapidly deteriorates GCS 4 E1V1M2 + Irregular pupils + Airway obstruction + Immediate transfer to Resus + Prepare for

Psychology Clinical Case Presentation

Transcript: Psychology Clinical Case Presentation An In-Depth Analysis of Client Treatment and Outcomes Mental State Exam Presenting Problem and History The mental state exam revealed significant findings, including elevated anxiety levels, mood fluctuations, and cognitive distortions. Notable features included impaired insight and fluctuating affect, which indicated underlying psychological distress. Understanding the presenting problems in a clinical context is crucial for effective diagnosis and treatment plans. Each client's history and state at presentation provide significant insights into their psychological conditions. Referral Source and Reason Service Delivered The treatment was delivered at a community mental health clinic specializing in anxiety and mood disorders. Services included individual therapy sessions focused on cognitive-behavioral therapy (CBT), which aimed to equip the client with coping strategies and skills to manage symptoms effectively. Treatment History The client was referred to therapy by her primary care physician due to persistent anxiety and depressive symptoms. The physician highlighted concerns regarding the client's ability to manage daily responsibilities at work and home, prompting the need for psychological intervention. Key Features of Presentation Demographic Details The client has undergone several treatment plans, including cognitive-behavioral therapy and medication management. While some approaches yielded temporary relief, the lack of consistent adherence to treatment plans hindered sustained progress. Key features of the presentation include persistent avoidance behavior and negative self-image. The client also demonstrated heightened emotional reactivity, impacting social interactions and daily functioning. The client is a 28-year-old female, living with her partner and two children. Educationally, she holds a bachelor’s degree in psychology and has been employed as a high school teacher for five years. Family dynamics are supportive yet strained due to work-related stressors. Client Details Changes Over Time Current Topography and Impact This section provides a comprehensive overview of the client’s background, including key demographic data, referral reasons, specifics of the service delivered, and the number of sessions conducted. Understanding these elements is crucial for contextualizing the therapeutic journey and outcomes. Number of Sessions The current topography of symptoms includes intrusive thoughts and difficulty managing emotions. The impact is significant, leading to impaired relationships and occupational challenges due to heightened anxiety and depressive symptoms. Over time, the client's symptoms have oscillated between mild to severe, with increased episodes of panic associated with stressors in life. Historical treatment engagements indicated some responsiveness to earlier interventions, yet relapses occurred without sustained support. The client participated in a total of 12 therapy sessions over a period of three months. Each session lasted approximately 60 minutes, allowing for consistent progress tracking and adjustments to the treatment plan based on the client’s evolving needs. Health and Medical Status A comprehensive understanding of the client’s health history is vital. Past medical issues, including chronic illnesses and developmental milestones, significantly influence psychological outcomes, especially in children and adolescents. School Environment Community and Cultural Connection Connection to community and cultural identity can enhance coping mechanisms and provide support systems. Cultural practices and community ties deeply influence the client’s perspectives on mental health and treatment acceptance. The school environment shapes academic performance and social skills. Challenges such as academic pressure, teacher relationships, and school climate can contribute to mental health issues, making education a critical area for intervention. Diagnostic Issues Peer Relationships Peer interactions are essential for social development and emotional support. The quality of friendships and the presence of conflict or bullying can significantly affect the client's self-image and mental state, exacerbating existing issues or contributing to new ones. Psychosocial Background Applicable Diagnostic Categories Understanding a client's psychosocial background is crucial for effective treatment planning and prognosis. This section examines various societal and familial factors that significantly impact the client's mental health. Formulation: Understanding Client Challenges Understanding diagnostic issues is crucial for proper case formulation and treatment planning. Accurate diagnosis can significantly influence therapeutic outcomes and client engagement. Several diagnostic categories may apply to the case, such as Major Depressive Disorder, Generalized Anxiety Disorder, or Adjustment Disorders. Identifying the correct diagnosis is essential for

Clinical case Presentation,

Transcript: Justification Treatment to date Progression What ? Impact on my treatment plan Clinical case Presentation, Wednesday the 29th of January 2014 By Sigrid Aakre Treatment plan Improvements Now What Self reflection Treatment three, a pivot point So What ? Working Hypothesis Summary of the patient Risk Factor and Red Flags Differential Diagnosis Examination

Clinical Case Presentation

Transcript: Name: D.R.M Gender: Male Age: 38 y/o Race: Filipino Height: 154 cm Weight: 66kg Date admitted: March 13, 2016 medications goals / therapeutic management DIAGNOSTIC / LABS : " body weakness " astrocytoma "astrocytes" "-oma" -tumor March 22 WBC : 22.83 (H) Hgb : 175 (H) Hct : 0.54 (H) Neutrophils : 0.90 (H) Microbiology Specimen : Endotrachel aspirate Specie : Enterobacter aerogenes resistance: Amox-Clav., Cefaclor Sensitivity: Ciprofloxacin, Meropenem, Imipinem Gram Stain gram negative rods gram negative cocci pus cells patient's profile DIAGNOSTIC / LABS : astrocytes star-shaped neuroglia cells. has microfilaments - for support Blood brain barrier - for selective permeability March 23 GCS 3 March 24 no brain function march 25 Pneumonia, both lower lobes March 27 Astrocytoma VAP Diabetes Insipidus SIGNS AND SYMPTOMS: ? pharmaceutical care plan DIAGNOSTIC / LABS : March 18 CT Scan : tumor oligodendroglioma w/ cerebral swelling. March 20: Clinically brain dead. March 21: Diabetes inspidus Fluctuating BP 3 days PTA, the patient complains of generalized body weakness. Patient is diagnosed with intracerebral left frontal mass. S/P biopsy AD : medial frontal body of corpus callosum tumor S/P biopsy. FD : medial frontal body of corpus callosum tumor, Astrocytma Clinical Case Presentation thank you. PATHOPHYSIOLOGY: Reporter: Korina V. Tuano chief complaint: Biopsy: Astrocytoma, grade II -III, unresectable tumor date: pharmaceutical care issues: intervention : follow up: 3/29 Domperidone, Terlipressin, Ivabradine monitor QT BP, HR, Tachycardia, (these agents prolong QT interval) prolongation or Bradycardia (LEXICOMP) 3/29 Clopidogrel and Esomeprazole may use Prothrombin time (esomeprazole may diminis effect lansoprazole FDT w/c can be crushed (pxnt is on NGT. (PubMed) diagnosis: history - korina

Clinical Case Presentation

Transcript: Questions? Does ambulating increase risk for PE or new DVT? Compared four randomized trials found on research databases Compared: ambulation and compression vs bed rest and compression ambulation and compression vs bed rest alone No significance in development of PE or new thrombus Ok to prescribe ambulation for DVT patients Education Plan Enoxaparin (Lovenox) 130 mg SQ q12 hr Acetaminophen (Tylenol) 650 mg PO q4 PRN Tramadol 50 mg PO q6 PRN 49 year old male, 230 lbs Presented to UVMC with R calf pain Acute saddle pulmonary embolism without acute cor pulmonale, bilateral DVT Admitted to Birchwood 10/15 Ambulating with walker, stand by assist References Tuesday: Patient will read provided literature. Patient will verbalize any questions over medication Thursday: Patient will teach back medication highlights (purpose, side effects, precautions) Long term: Patient will state that he has sufficient knowledge of medication before discharge from Birchwood Nursing assessment of clients at risk of deep vein thrombosis (DVT): the Autar DVT scale Clinical Case Presentation Tuesday: Patient will safely ambulate with RW for 10 min, 2 times per shift Thursday: Patient will saftly ambulate with RW for 10 min, 3 times per shift Long term: Patient will be able to ambulate without use of assitive decice by date of discharge Ambulation after Deep Vein Thrombosis: A Systematic Review Cathy M. Anderson, Tom J. Overend, Julie Godwin, Christina Sealy, Aisha Sunderji Sand-Jecklin, K. (2007). The impact of medical terminology on readability of patient education materials. Journal Of Community Health Nursing, 24(2), 119-129 11p. Rationale Knowing the pt's preffered leardning mode will allow customization of the teaching plan, help the teaching stick Allows nurse to gauge where they need to concentrate eduction, able to correct misunderstood information Additional chance to see what they have already been taught Coallboration ensures patient knows goals, helped make Education should be reinforced with patient appropriate reading material Method gives patient opportunity to ask questions, steer direction of discussion, elaborate Goals Problem: Knowledge deficit Related to: New long-term anticoagulation treatment As evidenced by: Request for more information on Enoxaparin Data: "I would like to make menu choices that are safe with Enoxaparin" "They didn't tell me much in the hospital about this medication" Evaluation Plan of Care https://www.uvmhealth.org/medcenter/Pages/eHealth/HealthwiseContent/default.aspx?hid=d03041a1 Assessment Assess pain before, during, after ambulate using numerical pain scale Assess gait while ambulating Preform Homan's test Care Stand by assist while ambulating Discuss PRN medications and benefits of taking before ambulating Arrange objects in room to allow for safe ambulation Consult with physical therapist, attend sessions Prompt pt to do PT prescribed exercises while in room Suggest sitercise attendance Research Education Anderson, C., Overend, T., Godwin, J., Sealy, C., & Sunderji, A. (2009). Ambulation after deep vein thrombosis: a systematic review. Physiotherapy Canada, 61(3), 133-140 8p. doi:10.3138/physio.61.3.133 Medications Patient Health Problem and Medications Ellie Anderson http://www.drug3k.com/drug/Lovenox-11588.htm http://www.dvtanswers.com/AboutDVT/symptoms-illustration.html http://www.mayoclinic.org/healthy-lifestyle/healthy-aging/multimedia/walker/sls-20076469?s=1 https://www.pinterest.com/pin/227220743674908523/ http://www.vibrantlifenames.com/karl/E/A/1/t2.htm https://www.uvmhealth.org/medcenter/Pages/eHealth/HealthwiseContent/default.aspx?hid=d03041a1 Anderson, C., Overend, T., Godwin, J., Sealy, C., & Sunderji, A. (2009). Ambulation after deep vein thrombosis: a systematic review. Physiotherapy Canada, 61(3), 133-140 8p. doi:10.3138/physio.61.3.133 Autar, R. (1996). Nursing assessment of clients at risk of deep vein thrombosis (DVT): the Autar DVT scale. Journal Of Advanced Nursing, 23(4), 763-770. doi:10.1111/1365-2648.ep8543738 Sand-Jecklin, K. (2007). The impact of medical terminology on readability of patient education materials. Journal Of Community Health Nursing, 24(2), 119-129 11p. Rationale Pain can inhibit ability/motivation to ambulate, evaluate how ambulation effects pain level Look for gait pattern alteration and quality of movement to see if pt is favoring painful limb, look for potential fall risks (shuffling, dragging feet) Dorsiflexion test to indicate (with caution) a DVT, observing if it pain from test worsen with ambulation Stay near pt when ambualting to monitor safety and assist if needed Better to stay ahead of pain then catch up, taking PRN pain medication 30-60 min. before ambulating may help decrease overall pain caused by ambulating Cluttered floor/room is a safety hazard, clearing a path decreases risk of fall Collaborating with PT will provide more insight into patient progress and goals Encourage pt to preform exercises while in room to improve ROM,

Clinical Case Presentation

Transcript: Fundamental Therapy Solutions Goals 9 year old male in 3rd grade Behavior: Amazing behavior. Very calm and compliant. Diagnosis: Dyslexia Evaluation: 9yrs 2 m CELF 5- within normal range Core Language 102 Receptive Language 103 Expressive Language 108 Mild deficits in social pragmatic language Clinical observations significant progress in reading and spelling, but still has large deficits in these areas. School spelling words LiPS program Prewritten paragraph deck edit HELP for Language book (idiom worksheets) Phonological Awareness: Track 3-4 syllable words with 80% accuracy. Pragmatics: Problem solve appropriately in 4 out of 5 trials. Pragmatics: Ask for help when appropriate in 4 out of 5 trials. Reading: Retell a story including main ideal and supporting details with 80% accuracy. (GOAL MET) Reading Fluency: Read grade-level text at 110 words per minute. (GOAL MET) Reading: Read age appropriate words (2-3 syllables) including short and long vowel sounds with 80% accuracy. Spelling: Spell age appropriate words (2-3 syllables) including short and long vowel sounds with 80% accuracy. Receptive Language: Improve memory recall for details on tasks such as spelling, retelling a story, or therapy activities with 80% accuracy. Receptive/Figurative Language: Identify and interpret the meanings of idioms, metaphors, similes, or proverbs with 80% accuracy. Expressive Language: Edit a pre-written paragraph for errors with spelling, punctuation, grammar, and mechanics with 80% accuracy to improve reading and spelling ability. Clinical Case Presentation Janelle Logan Patient T Based on the results of the reevaluation the client would continue to benefit from reading and spelling intervention 2x/week for 60min. Prognosis: Good. Counseling: Everyday we talk to dad and give him things to practice at home. Also, dad just told us that T went from a D in Language Arts to a C which he was excited about. I plan for T's sessions now. I tried to add in a game during therapy, but T couldn't focus so now we are back to more drill. I wouldn't change anything. Funtherapysolutions.com Out Patient Pediatric SLP, OT, and Psychologist Variety of patients: Delayed language Articulation Autism Expressive/Receptive Language Delay Dyslexia ETC... Therapy Materials

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