Case Study 8: Mr. Dennis presents with bizarre and aggressive behaviors. Refer to assignment directions in Tab #2 for further information.

Your writing assignment should:

follow the conventions of Standard English (correct grammar, punctuation, etc.);
be well ordered, logical, and unified, as well as original and insightful;
display superior content, organization, style, and mechanics; and;
use APA formatting and citation style.
Assignment Requirements:

Assignment Directions

Case Study Scenario:

You are a PMHNP working on an inpatient geriatric psychiatry unit. Your new admission today is Mr. Dennis, a 72-year-old single male resident from an assisted living facility. He was brought to the emergency department with “physical aggression and bizarre behaviors.” Mr. Dennis. has no known premorbid psychiatric history. Two years ago, he was diagnosed with a mild neurocognitive disorder, major depressive disorder, and generalized anxiety disorder. He is unmarried with no children and lived independently in an apartment until 6 months ago. His recent symptoms of depression and anxiety were attributed to his transition to retirement from teaching at age 65. He had worked as a high school mathematics teacher for 3 decades and was highly active in his local church. Following his retirement, his cognitive decline progressed, and he subsequently began to experience progressive Parkinsonian symptoms, including mild intention tremor, cogwheeling rigidity, and bradykinesia. Recurrent falls and functional decline led to his eventual admission to the assisted living facility, as he required assistance with bathing, dressing, cooking, and medication management. He was seen by the facility’s physician and referred to a neurology service to evaluate his Parkinsonian symptoms.

Assisted living staff members report that he appears intermittently confused and disoriented and endorses visual hallucinations of insects and children in his room. He was initially insightful regarding these perceptual disturbances and easily reassured by staff. He was often seen in his room contentedly interacting with hallucinatory figures. Over the past month, he has expressed concerns that someone in the facility wants to harm him and that “nothing is real.” With no apparent trigger, he has repeatedly become increasingly volatile and physically aggressive toward co-residents. At other times he appears entirely lucid and engages appropriately with staff and co-residents. His sleep is erratic, and he has been observed thrashing his legs in his bed on nightly rounds. He is eating well, has normal bowel and bladder function, and denies any pain. There are no intercurrent medical illnesses and no infectious symptoms noted. There is no known family psychiatric history.

Past medical history is significant for dyslipidemia treated with a statin. He otherwise does not have any vascular risk factors. There is no history of traumatic brain injury. He is a non-smoker and a nondrinker with no illicit drug use. His current medications include atorvastatin 40 mg po daily and risperidone 0.5 mg po qhs, which the facility’s physician recently started for psychosis. There are no known drug allergies.

On physical examination in the emergency department, Mr. Dennis. presented as afebrile with normal vital signs, and worsening Parkinsonian symptoms were noted. The emergency physician noted that he appeared “perplexed” and endorsed visual hallucinations of small animals running around the ward. Mental status examination revealed a casually dressed and mildly disheveled older male who seemed his stated age. He presented as confused but was able to tolerate a short interview. The speech was of normal rate, rhythm, and volume. The mood was described as “not bad,” and the affect was slightly blunted. Thoughts were disorganized, and perceptions revealed prominent visual hallucinations. He denied suicidality and homicidality. Insight and judgment were impaired due to confusion. Brief cognitive testing showed a MoCA of 21 out of 30, with deficits in visuospatial and executive function. Laboratory investigations showed dehydration and mild leukocytosis, with urine culture positive for E. coli bacteriuria. He was started on intravenous fluids and an antibiotic.

Use the SOAP note template to complete the documentation with the information provided.

Formulate appropriate diagnoses and design a treatment plan.
Explain what further information you will explore to aid in accurate diagnosis.
What treatment management is recommended for this patient, including pharmacological management?
Discuss any need for referral.
Discuss evidence-based treatment approaches for a client with neurocognitive disorder.
Before finalizing your work, you should:

be sure to read the assignment description carefully (as displayed above);
consult the Grading Rubric (located in Course Resources, Grading Rubrics submodule) to make sure you have included everything necessary; and
utilize spelling and grammar check to minimize errors.
Your writing assignment should:

follow the conventions of Standard English (correct grammar, punctuation, etc.);
be well ordered, logical, and unified, as well as original and insightful;
display superior content, organization, style, and mechanics; and
use APA 7th edition format.

***SOAP note attached