NU 671 Unit 7 collateral information summary example

Collateral Information Summary for Mr. K.: Four Sources, Kept Separate, and Where Their Accounts Diverge

Student Name

Department of Nursing, Herzing University

NU 671: Clinical Decision-Making in Psychiatric Mental Health

Instructor Name

March 5, 2026

Collateral Information Summary for Mr. K.: Four Sources, Kept Separate, and Where Their Accounts Diverge

Sources and Consent

Mr. K., whose evaluation is under way for apathy, fatigue, cognitive complaints, and low mood, gave written consent to contact his wife and adult daughter and to obtain records from his primary care clinic and pharmacy. Collateral information is a standard part of psychiatric evaluation, particularly when cognition or substance use may affect a person's own account (American Psychiatric Association, 2016). Each source is summarized in its own section, with every statement attributed and dated. Nothing is merged across sources.

Source 1: His Wife, Interviewed in Person on February 24

She has been married to him for 31 years and sees him daily. She dates the change to "about a year and a half ago, the summer before last," when he stopped going fishing with his brother-in-law. She describes him as "not sad exactly, more like the light went out." He falls asleep in his chair every evening by 8. His snoring has been loud for "at least five years" and she has watched him stop breathing, "sometimes for what feels like half a minute." She reports that he drinks "three or four beers every night, more on the weekend." She has noticed that he forgets conversations and repeats questions. When asked specifically, she said he has not become rude, impulsive, or careless with money, has not lost interest in personal hygiene beyond shaving less, and has not shown new unusual food preferences. She completed the 16-item short form of the informant questionnaire known as the IQCODE (Jorm, 1994); her ratings averaged 3.4, where 3 represents no change over ten years and higher scores represent decline.

Source 2: His Daughter, by Telephone on February 26

She moved back into her parents' home with her two children 18 months ago. She describes her father as "tired all the time" and "not himself." She reports that he forgot her son's baseball game twice and told her the same story about work twice in one evening in January. She has not noticed changes in his drinking, but said, "I don't really watch." She described the household as crowded and noisy, and said her father has been getting up at 5 a.m. to have quiet time before the children wake.

Source 3: Primary Care Records, Received February 20

Hypertension diagnosed eight years ago, treated with metoprolol throughout. Last thyroid test before this evaluation was in 2019, within the reference range. Weight 208 pounds in 2023, 226 pounds in 2025. Sertraline was started at 50 mg on September 20, 2025, increased to 100 mg on November 1, and to 150 mg on December 13. No documented discussion of sleep, snoring, or alcohol.

Source 4: Pharmacy Fill History, Received February 22

Metoprolol filled every 30 days without gaps. Sertraline filled at each dose, with gaps between the expected and actual refill dates of 4 days in October, 7 days in December, and 8 days in January, about 19 days without medication over the 124 days from starting sertraline to the intake visit, or about 85% of days covered. Pharmacy refill records are a validated, if indirect, measure of medication adherence (Steiner & Prochazka, 1997).

Where the Accounts Diverge

Onset: Mr. K. said the change began "about a year ago"; his wife dates it to about 18 months ago. The difference matters because the earlier date is before his daughter moved in and before his promotion, weakening those events as the trigger.

Alcohol: Mr. K. reported about two beers most nights and six on Saturdays, about 16 a week; his wife reports three or four every night and more on weekends, which would be roughly 25 or more a week. His daughter does not know. The wife sees him daily and has no apparent reason to exaggerate, but she may also be estimating. The discrepancy is recorded rather than resolved, and the higher estimate strengthens alcohol as a contributor.

Treatment adequacy: the referral described four months of sertraline without response. The records show only about six weeks at the 150 mg dose by the time of the intake visit, preceded by lower doses, and about 15% of days without medication. The trial was shorter and less complete than the referral suggested.

Personality and behavior: his wife's specific denial of disinhibition, loss of social awareness, and new food preferences is useful negative information, since those changes would raise concern for frontotemporal degeneration.

What the Collateral Changes

Three conclusions change. The antidepressant trial should not yet be called a failure; it was shorter at full dose and less consistent than reported. Alcohol use may be substantially higher than he reported, which strengthens its role and makes the brief intervention a priority. And the negative findings on behavior and personality lower the concern for frontotemporal degeneration, while the long history of loud snoring with observed pauses supports the sleep apnea diagnosis as long-standing. These points were discussed with Mr. K., who said that his wife was probably right about the beer.

References

American Psychiatric Association. (2016). The American Psychiatric Association practice guidelines for the psychiatric evaluation of adults (3rd ed.). American Psychiatric Association. https://doi.org/10.1176/appi.books.9780890426760

Jorm, A. F. (1994). A short form of the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE): Development and cross-validation. Psychological Medicine, 24(1), 145-153. https://doi.org/10.1017/S003329170002691X

Steiner, J. F., & Prochazka, A. V. (1997). The assessment of refill compliance using pharmacy records: Methods, validity, and applications. Journal of Clinical Epidemiology, 50(1), 105-116. https://doi.org/10.1016/S0895-4356(96)00268-5