David is a 73 year old man who retired 4 years ago after being a lawyer for 45 years. He states ?I?m in good health?, he takes medications for hypertension and had said to his son he might mention some ?waterworks? problems the next time he saw his primary care provider. 2 years ago his second wife of 5 years died unexpectedly of an abdominal aortic aneurism.

He developed some anxiety after this happened but wouldn?t take any ?addictive pills? so his PCP gave him low dose Paroxetine. He and his son have always been close and David frequently visited them. His son said when his Dad was not volunteering, or visiting friends and family he exercised, ate well and kept his medical/dental/eye appointments.

You (the geriatric psych NP) have been asked to evaluate David today after he ended up in the ER feeling weak, having lost weight, and not functioning at baseline. His electrolytes and EKG were significantly enough abnormal that he was admitted to a medicine floor. The son reports 1 month ago his Dad stopped coming to the house to see him and his family, and his Father?s longtime friends called him stating they were worried about how David was acting, that he wasn?t able to keep up at the weekly poker game, had 3 beers instead of his usual 1 beer and his newspapers were piling up outside his house.

Alarmed, the son went to his Father?s house, he noted both newspapers and mail were piling up. He found his Dad thin, unshaven or showered, in the dark, irritable and with a foul odor. David said he was fine and to leave him alone, he?d fallen a few times but was ?ok?, the ?waterworks? were a problem but gave no other details. The answering machine was blinking and had 19 messages listed. There was not much food in the house and David said he wasn?t hungry, admitted under duress he wasn?t sleeping well and his pill bottles were on the kitchen table. Usually David filled his pill box on Sunday but he said he couldn?t find them currently.
1. What 3-5 priority physical assessment questions and exams would you undertake with David?
2. What 5-7 priority psychiatric assessment questions and evaluations would you recommend for David?
3. What labs/imaging studies would you order and why?
4. List your differential psychiatric and medical diagnoses. Discuss the support for/against the items on your differential. Correlate the psychiatric and physical assessment questions to the items on your differential list.
5. Pick the psychiatric diagnosis you feel best suits the case and explain why; list the medical diagnoses present also.
6. Do a review of the nursing literature, literature from other disciples that you feel are appropriate for your patient and any expert consensus documents and use the literature as the basis for your top 3 treatment recommendations. You must use at least 1 nursing research

Paper grading Rubric
1. Very well organized _____(2 points)
2. Easy to understand, insightful, critical thinking demonstrated_____(2 points)
3. Uses APA style on title page and references_____(3 points)
4. Analysis of the clinical case is creative, critical and well thought out _____(2 points)
5. Student picks out relevant assessment information_____(2 points)
6. Does research, analyzes clinical case and justified choice of diagnosis_____(3 points)
7. Treatment plan is congruent with assessment and diagnosis_____(3 points)
8. Answers all the questions in a concise, specific and integrative way; looks at the mind/body connection