A  is a 72-year-old African American female who came in for psychiatric evaluation for anxiety and people following her around. client is a retired home health care aid and was referred by her PCP for psychiatric evaluation and follow up.

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 For this Assignment, you will document information about a patient. Focused SOAP Note Template provided. You will then use this note to develop and record a case presentation for this patient. Be sure to incorporate any feedback you received

Subjective:

CC (chief complaint): snice I separated from my husband people have been following me around

HPI: O.A  is a 72-year-old African American female who came in for psychiatric evaluation for anxiety and people following her around. client is a retired home health care aid and was referred by her PCP for psychiatric evaluation and follow up. Client report that she is separated from her husband because her husband had affair and she had to leave him, he was causing a lot of trouble for her, he was spraying things in the house so she will get sick , she had to call police 2 to 3 times, then people started following her everywhere watching her going to store, few times she tried to drive away from them b/c they were chasing her with car. Client report that she finally left home and is living with her daughter now. Client said her problem started about 1 year ago, she was married to her husband for 30 years and separated one year ago. She saw a doctor 2 months ago, was given Risperidone 0.25 mg daily, she took it but it did not help, then she went to Canada with her cousin who took her to see psychiatrist there and she was given Abilify 2 mg QAM and 5 mg QHS which she is taking for 4 weeks now and she feels better, not anxious that much, and people are not following her as much, but still believes they follow her, claims her husband had asked these people to follow her. Client said she is sleeping well, appetite is good, denied any suicidal or homicidal thoughts, denied any hallucination. Diagnosis is unspecified psychosis not due to a substance or known physiological condition [f29] Plan is for client to continue Abilify 2.5 mg po QAM and 5 mg po QHS since she seems to be responding well to Abilify and return for follow up in one month.

 

Substance Current Use:

Medical History:

 

  • Current Medications:
  • Allergies:
  • Reproductive Hx:

ROS:

  • GENERAL:
  • HEENT:
  • SKIN:
  • CARDIOVASCULAR:
  • RESPIRATORY:
  • GASTROINTESTINAL:
  • GENITOURINARY:
  • NEUROLOGICAL:
  • MUSCULOSKELETAL:
  • HEMATOLOGIC:
  • LYMPHATICS:
  • ENDOCRINOLOGIC:

Objective:

Diagnostic results:

USE this Diagnostic  DSM-5 diagnostic criteria

  • Psychosis not due to a substance or known physiological condition [f29]
  • 9 Anxiety disorder. Unspecified
  • F 31.9 Bipolar disorder, unspecified

Assessment:

Mental Status Examination:

Diagnostic Impression:

Reflections:

Case Formulation and Treatment Plan:

Reflect on this case. Include: Discuss what you learned and what you might do differently. Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), social determinates of health, health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).

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In the Assessment section, provide:

•  Results of the mental status examination, presented in paragraph form.

•  At least three differentials with supporting evidence. List them from top priority to least priority. Compare the DSM-5-TR diagnostic criteria for each differential diagnosis and explain what DSM-5-TR criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.

1st Diagnostic: Opiods Abuse with withdrawals (F11.13)

2nd Diagnostic: Depression Disorder (F33.1)

3rd Diagnostic: Post Traumatic Stress Disorder (F43.10)

Reflect on this case. Include: Discuss what you learned and what you might do differently. Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), social determinates of health, health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).

The student provides an accurate, clear, and complete diagnostic impression with three (3) differentials. … Reflections are thorough, thoughtful, and demonstrate critical thinking. …Reflections contain all 3 elements from the assignment directions.

References must be provided…

 

Answer

Week 9: Focused Soap note and Patient Case Presentation

 

College of Nursing-PMHNP, Walden University

PRAC 6635: Psychopathology and Diagnostic Reasoning

 

CC (chief complaint): “I want to die, if I don’t get my pain medications”.

HPI: Patient (D.J.) is a 29-year-old, white, Hispanic male, unmarried, presented to JBHH-ED by LEO for suicidal ideation. The patient originally went voluntary to the medical hospital asking for Dilaudid due to pain. Patient said he received 8 gunshot in 2016 in chest/abdomen and legs related to gang violence. During the interview with the patient, he admitted that he was injecting fentanyl for pain and now is having symptoms of withdrawal. Patient had a lose stool if front of me and he is requesting pampers. Patient reports is living with his aunt. The patient endorses psychiatric symptoms of opioid withdrawal. The patient has history of several hospitalizations for Opioids usage.

Past Psychiatric History:

  • General Statement: Patient started using opioids after 8 GSW to chest/abdomen/leg. He initially started with Oxycodone 6-7 pills daily, starting Oxycodone months ago which he receives form a friend, and currently has been injecting 1 gram of fentanyl daily for this year. He has tried Suboxone which had helped him with cravings. Patient states he is prepared and determined to quit. He is currently interested in going to an outpatient program. Patient is currently being tapered off of alprazolam which he has taken since 2021 for anxiety and PTSD.
  • Caregivers (if applicable): Mother
  • Hospitalizations: Patient had multiple hospital admissions for low mood and was at a rehab facility after GSW. He has been taken pain medications since the gunshot wound. Patient has been placed into 4 residential Rehab programs in the past which was not successful. Patient is now agreeable to go to another inpatient Rehab again. He denies having any death wishes/plan/intent at the time of this assessment.
  • Medication trials: Alprazolam 1mg  Oral,  TID; Buprenorphine 8mg Tab, Sublingual BID
  • Psychotherapy or Previous Psychiatric Diagnosis: The patient was previously diagnosed with PTSD, Schizophrenia, Anxiety, and Opioid abuse. The patient was once sent to a rehab program result was not successful.

Substance Current Use and History:

The patient reports daily usage of Fentanyl since at the age of 20. Patient has been taking Dilaudid for his chronic back pain since his gunshot wound in 2016. Patient denies any alcohol usage. Denies smoking nicotine and denies any other illicit drugs. Patient can be seen going through withdrawals at his time as evidence by current diarrhea.

Family Psychiatric/Substance Use History:

The patient reports that his father did not used any drugs or have any psychiatric illness. His mother suffers from depression. Patient is living with his mother and father his father. Denies family substance abuse and denies family medical problems.

Psychosocial History: This patient was born in Hialeah, Florida, and he is currently living with his mother. Pt has a hx of opiate abuse and stimulant abuse. Previously attended rehab in the past. Reported using the following substances: Dilaudid and Fentanyl “alot” but daily, for pain. Reported starting drug usage after when he was shot in 2016. Patient did not finish high school. He was working as a computer engineer, but stop working after the accident.

 

 

Medical History:

  • Current Medications:

ALPRAZolam 2 mg oral tablet 2 mg = 1 tab, PRN, ORAL, TID

Baclofen 20 mg oral tablet 20 mg = 1 tab, ORAL, TID,

Gabapentin 600 mg oral tablet 600 mg = 1 tab, ORAL, TID,

Percocet 5 mg-325 mg oral tablet 1 tab, ORAL, Q6H

  • Allergies: Iodine; Nuts; Lovenox; Toradol
  • Reproductive Hx: Male, no children

ROS:

  • GENERAL: Alert, Awake X 4
  • HEENT: Pupils are equal, round and reactive to light, extraocular movements are intact. Oral mucosa moist. Normocephalic, atraumatic
  • SKIN: Warm, Denies rash, Denies swelling, Denies lacerations, Denies abrasions
  • CARDIOVASCULAR: Regular rate and rhythm
  • RESPIRATORY: Lungs are clear to auscultation, no tenderness
  • GASTROINTESTINAL: Denies nausea, Denies vomiting, Denies diarrhea, Denies constipation, Denies bloating, Denies melena
  • GENITOURINARY: Denies Dysuria, Denies frequency, Denies flank pain, Denies hematuria
  • NEUROLOGICAL: Alert and oriented to person, place, time, and situation. No focal neurological deficit observed.
  • MUSCULOSKELETAL: Normal ROM.
  • HEMATOLOGIC: No bruising, No petechiae, No bleeding noted
  • LYMPHATICS: Denies any swollen nodes
  • ENDOCRINOLOGIC: Denies polyuria, Denies polydipsia, Denies polyphagia

Physical exam: No physical exam is required at this time.

Diagnostic results: TSH, CPM, BMP, CBC, and labs would be performed to rule out any psychiatric symptoms related to medical conditions. The Mood questionnaire would be provided to the patient to assess for bipolar disorder.

Assessment:

Mental Status Examination:

Patient is 29 years white, Hispanic male evaluated today, patient reports in moderate distress 2/2 to w/d and with poor eye contact, minimally conversation. Patient reporting moderate sx of w/d including muscle aches, nausea, restless, chills. Tolerated Subutex and amenable to continue Subutex for detox and motivated to stay on maintenance dose. The patient endorses psychiatric symptoms of opioid withdrawal, resting pulse <80,  yawning, restlessness, pupil size normal size for room light without pathologic dilation, bones or joint aches, no rhinorrhea,  tremor, no gooseflesh,  anxiety, irritability, GI upset, no sweat, COWS=14.  Patient states he also has a dx of PTSD and prescribed Alprazolam 2mg TID by outpatient psych. per patient information he was last prescribed alprazolam 1mg TID. Pt is not forthcoming with all information at this time, as he kept stating, “I don’t know, I don’t know”. Discussed plan to continue at most recent dose to avoid benzo w/d given chronic use.  Denies and not noticed any sxs of psychosis, mania, depression, anxiety, adamantly denies any active suicidal thoughts nor death wishes, intent or plan.

Differential Diagnoses:

Reflections:

Kazim Ali’s “Notes on Silence” is an imaginary syllabus for a semester-long college course devoted to (if not conducted in) silence. What are some intriguing implications raised by this text? What is the communicative power of not speaking?

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Kazim Ali’s “Notes on Silence” is an imaginary syllabus for a semester-long college course devoted to (if not conducted in) silence. What are some intriguing implications raised by this text? What is the communicative power of not speaking? Is true silence ever entirely possible? In this ongoing era of so-called “information overload,” are we suffering from a silence shortage? Can this be cured?

Larissa Lai’s “Salt Fish Girl” is an ode celebrating female creativity—is there anything potentially blasphemous (or empowering) in the phrasing of “In the beginning, there was just me”? How might the title character here have existed even while “The materials of life still lay dormant”? Does this imply that our soul exists before our anatomy does? What is being expressed and explored in the image of a fish-woman capable of molding new lives out of fresh clay?

HEWLETT-PACKARD’S CURRENT PROBLEMS WITH INTERNATIONAL KICKBACKS

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CASE STUDY 28:

Fighting International Fraud with the FCPA

Priscilla Burnaby, Ph.D., CPA

Bentley University

Susan Hass, MBA, CPA, CGMA

Simmons College

Brigitte W. Muehlmann, Ph.D., MST, CPA, CFM, CVA

Suffolk University

LEARNING OBJECTIVES

After completing and discussing this case, you should be able to

Find financial irregularities in financial statements.
Analyze trends in account balances.
Perform horizontal, vertical, and trend analysis.
Compare financial ratios to industry averages.
Gain a better understanding of the accuracy/effort trade off. Analyze the statement of cash flows.

HEWLETT-PACKARD’S CURRENT PROBLEMS WITH INTERNATIONAL KICKBACKS

Andrew and Susie were on a Midwest college campus discussing current events over lunch. Susie found an article about one of the topics they were studying in law and fraud class and brought it to Andrew’s attention, “Andrew I just read in the Wall Street Journal (Crawford, 2012) that the Hewlett-Packard (HP) criminal bribery case we studied in class last semester is finally heating up. Remember the case was about a German branch of HP bribing a Russian official. The ar- ticle says that German prosecutors filed bribery, tax evasion and embezzlement charges against Hilmar Lorenz, a German and former H-P marketing executive in Russia; Ken Willett, a Germany-based American H-P manager; and Päivi Tiippana, a Finn and former manager at the company. Prosecutors also indicted Ralf Krippner, a local German politician and businessman as an accessory.

The indictment alleges that Krippner billed an H-P subsidiary for services that were never performed and helped relay the funds.” Susie noted, “This case

200 Case Studies in Forensic Accounting and Fraud Auditing

has not yet been brought to a U.S. court. The Securities and Exchange Com- mission (SEC) is still investigating. If I remember correctly from articles we read (Yannet and Fuhr, 2010), the investigation began in 2007 after a German tax auditor became suspicious of payments totaling €22 million that a German HP subsidiary made to a small computer hardware firm near Leipzig from 2004 to 2006. They suspect Russian officials received €7.5 million in kickbacks for a € 35 million dollar contract to sell computer gear to Russia‘s Prosecutor General Office, the very office responsible to stop bribes. (Crawford, 2012)”

Susie continued, “The HP subsidiary recorded the payments as having been made for services rendered in Moscow. The investigation also identified three payment intermediaries (shell companies in multiple jurisdictions) and a Moscow- based computer supplier with foreign bank accounts as having conspired with HP to perpetrate the alleged bribery scheme. Using HP funds, the intermediaries, based in the former East Germany, allegedly paid fake invoices for equipment to the shell companies. The illicit funds then flowed through bank accounts all over the world, including the U.K., the U.S., New Zealand, the British Virgin Islands, Latvia, Lithuania, Belize, Austria, and Switzerland before making their way to Russia. (Yannet, and Fuhr, 2010)

This story is an international intrigue. The SEC has yet to file charges using the Foreign Corrupt Practices (FCPA) Act of 1977. It amazes me how long it takes to bring these people and companies to justice. And, it seems like the HP employees did not even benefit from the fraud except for getting credit for the sale.1 I am looking forward to studying more international FCPA violations in our fraud and forensics course. It really takes a lot of information gathering and drilling down into the details to be able to bring a case like this to court. Andrew, what I don‘t get is that I thought all these U.S. companies have a code of conduct and policies to prohibit their employees from offering bribes to foreign officials. I thought the FCPA required that U.S. companies have accounting systems with adequate controls to prevent these fraudulent kickbacks. It has been years since the law was passed. How can this still be happening?”

STUDENT ASSIGNMENTS

Individual Assignments

Although the FCPA has been around since 1977, it is not until the last 12 years that the SEC has annually indicted multiple U.S. companies doing business in foreign countries using the FCPA. To gain an understanding of the FCPA, go to the SEC‘s website http://www.sec.gov/spotlight/fcpa.shtml and click on the FCPA (Securities and Exchange Commission, 2012b) hyperlink on the bottom left.

Fighting International Fraud with the FCPA 201

Then, answer the following questions.

  1. Download the document, A Resource Guide to the U.S. Foreign Corrupt Practices Act (Criminal Division of the U.S. Department of Justice and the Enforcement Division of the U.S. Securities and Exchange Commission).
    1. Read Chapter 1, “Introduction,” which describes the scope of the FCPA, discusses the costs of corruption, and covers the evolution of the law as well as how the SEC partners with the Department of Justice to fine companies and imprison those that break the law. It also provides an introduction to the efforts of the Commerce and State Departments to assist U.S. companies by advancing anti-corruption and good governance initiatives as well as an introduction to the international landscape.
    2. Read Chapter 2, “The FCPA: Anti-bribery Provisions,” which explains the anti-bribery provisions.
    3. How can a law that was enacted more than 35 years ago still be relevant today?
  2. Review the annual list of enforcement actions by calendar year for the past five years. From the SEC website, select a sample of five companies to read about in more detail. What strikes you about the companies you reviewed and their crimes?

Go to www.cbsnews.com/8301-18560_162-4080920.html and view The Price of Bananas video. You will also find the transcript of the video at that

link. Be ready to discuss the video in class.

  1. Chiquita Banana was making payments to a militant group. How does this action fall under the FCPA?
  2. What would you have done if you were faced with threats of deadly action against those that worked at the Chiquita Banana facilities under your supervision?
  3. What has been some of the fallout for Chiquita Banana?
  1. Answer the questions in the FCPA Survey in the Appendix. Be ready to defend your choice based on your understanding of the FCPA and your personal beliefs.
  2. To learn about codes of conduct, read the article, “Up To Code,” by Paine, L., Deshpandé, R., Margolis, J., and Bettcher, K. (2005). Harvard Business Review, 83 (12), 122-133. Then answer the following questions:

202

Case Studies in Forensic Accounting and Fraud Auditing

  1. Should a company have a uniform global code of conduct policy? Why or why not?
  2. Should these policies be implemented globally, or at a regional, country, or local level?
  3. Should companies have specific global policies regarding gifts, gra- tuities, payments, entertainment, conflicts of interest, and related matters? Why?
  4. Who should be responsible for communicating, monitoring, and enforcing the company’s policy?