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CASE STUDY You are a PMHNP working at an inpatient psychiatric floor of a local hospital. You are evaluating a new patient, Helen. Helen is a 75 year old AA female who is living at home alone. Helen was brought to the hospital by family members who were concerned about her change in mental status. She was found to have a UTI and hyponatremia (Na+ 128). Helen was put on a fluid restriction and received a few doses of IV antibiotics, then transitioned to PO antibiotics. She has now transferred to psychiatry due to learned history of progressive cognitive decline and agitation with aggressiveness towards family members. Today Helen is restless and barely cooperative with the assessment. Her long term memory appears intact, but her short term memory is impaired. She failed proverb testing and is very concrete. A MoCA was done and she scored 16/30. You are unable to get the information and history that you need. MSE General Appearance: Poor hygiene, disheveled, thin. Behavior/Attitude: Distracted, minimally cooperative, mildly agitated Psychomotor Activity: restless. Weak gait. Mood: “I don’t know” Affect: neutral, irritable, full Speech: normal volume, rate, rhythm. Irritable tone. Rare spontaneity, minimal Thought Process: mostly organized and linear Thought Content: Does not endorse SI or HI. No apparent delusions noted. Thought Perception: Reported VH when on medical floor, denies currently. Denies AH. Does not appear to be responding to hallucinatory stimuli. Cognition: Alert to person and is aware she is in hospital. Concrete. Short Term memory impairment. Insight: impaired Judgement: impaired Discuss and answer the following: What differential diagnoses are you considering? What lab work will you order? What other screening tools would you consider? What legal and ethical concerns do you consider? How do you manage these concerns? What are some considerations/factors related to patient’s life span?

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