WEEK 7 M. Robinson
Client is being seen for the first time with this organization. Client has a hx of anxiety and depression that dates back to 2018. At the time she was being treated by her PCP WITH LEXAPRO, wellbutrin, and xanax.
She says after about 3 months, she stopped using the medication because she felt like it did not work. She says in 2019, she was involved in a volatile domestic relationship that included physical, emotional, and verbal abuse. She says in August 2021, her son was murdered.
She says initially she was having auditory hallucinations, but since then endorses racing thoughts, insomnia, waking up feeling tired, irritability, sporadic eating without any significant weight changes, isolating, excessive crying, and poor focus/concentration.
Denies si/hi and a/v hallucinations. Admits to drinking about 4 ounces of liquor daily. Denies any on-going medical problems, illicit drug usage, tobacco usage, and medication allergies.
Objective
Mental Status Exam
Orientation: Person, place, and time
Appearance: Neat hygiene and appearance
Behavior/Attitude: Pleasant, cooperative, guarded, paranoid, restless, anxious, withdrawn, disorganized, avoidant, resistant
Speech: Normal rate and rhythm; easily understandable, poverty of speech, pressured, rapid, loud, soft
Thought Process: No obsessions, preoccupations, or phobia noted; No si/hi; no delusions or ideas of reference; paranoid, delusional, bizarre, obsessive, grandiose
Mood: Euthymic, neutral, dysphoric, depressed, apathetic, anxious, elated, ecstatic, hypomanic, manic
Affect: Appropriate, Inappropriate, broad, constricted, euthymic, dysphoric, depressed, reactive, exagerated
Memory: Intact immediate, intact remote
Concentration: Intact, attentive, distracted, inattentive, confused
Insight: Good, fair, poor
Judgment: Intact, fair, impaired, poses imminent potential threat to others/self
Assessment
Diagnoses attached to this encounter:
(F33.1) Major depressive disorder, recurrent, moderate
(F41.1) Generalized anxiety disorder
(F43.12) Post-traumatic stress disorder, chronic
Plan
Referred to therapy
Started on vraylar 1.5mg and klonopin 0.5mg qam and 1mg qhs
Medication education given
RTC in 2 weeks
Educated on etoh being a depressant and sleep hygiene
Subjective: What details did the patient provide regarding their personal and medical history? What are their symptoms of concern? How long have they been experiencing them, and what is the severity? How are their symptoms impacting their functioning?
Objective: What observations did you make during the interview and review of systems?
Assessment: What were your differential diagnoses? Provide a minimum of three (3) possible diagnoses. List them from highest to lowest priority. What was your primary diagnosis and why?
Reflection notes: What would you do differently in a similar patient evaluation? Reflect on one social determinant of health according to the HealthyPeople 2030 (you will need to research) as applied to this case in the realm of psychiatry and mental health. As a future advanced provider, what are one health promotion activity and one patient education consideration for this patient for improving health disparities and inequities in the realm of psychiatry and mental health? Demonstrate your critical thinking.
Description of chief complaint and history of present illness–
Excellent 5 (5%) – 5 (5%)
The student provides an accurate, clear, and complete description of the chief complaint and history of present illness.
Good 4 (4%) – 4 (4%)
The student provides an accurate description of the chief complaint and history of present illness.
Fair 2 (2%) – 3 (3%)
The student provides a vague, inaccurate, or incomplete description of the chief complaint and history of present illness, or description is missing.
Poor 0 (0%) – 1 (1%)
The student provides a completely inaccurate, or incomplete description of the chief complaint and history of present illness, or the description is missing.
Description of past psychiatric, substance use, medical, social, and family history–
Excellent 5 (5%) – 5 (5%)
The student provides an accurate, clear, and complete description of past psychiatric, substance use, medical, social, and family history.
Good 4 (4%) – 4 (4%)
The student provides an accurate description of past psychiatric, substance use, medical, social, and family history.
Fair 2 (2%) – 3 (3%)
The student provides a vague, inaccurate, or incomplete description of psychiatric, substance use, medical, social, and family history, or description is missing.
Poor 0 (0%) – 1 (1%)
The student provides a completely inaccurate, or incomplete description of psychiatric, substance use, medical, social, and family history, or description is missing.
Discussion of most recent mental status exam and observations made during interview and review of systems–
Excellent 14 (14%) – 15 (15%)
The student provides an accurate, clear, and complete discussion of results from most recent mental status exam and observations made during interview and review of systems.
Good 12 (12%) – 13 (13%)
The student provides an accurate discussion of results from most recent mental status exam and observations made during interview and review of systems.
Fair 11 (11%) – 11 (11%)
The student provides a vague, inaccurate, or incomplete discussion of results from most recent mental status exam and observations made during interview and review of systems.
Poor 0 (0%) – 10 (10%)
All or most of the discussion is inaccurate or missing.
Discussion of diagnostics with results–
Excellent 9 (9%) – 10 (10%)
The student provides an accurate, clear, and complete discussion of diagnostics with results.
Good 8 (8%) – 8 (8%)
The student provides an accurate discussion of diagnostics with results.
Fair 7 (7%) – 7 (7%)
The student provides a vague, inaccurate, or incomplete discussion of diagnostics with results.
Poor 0 (0%) – 6 (6%)
All or most of the discussion is inaccurate or missing.
Diagnostic Impression with three (3) differential diagnoses
Reflection on this case–
Excellent 23 (23%) – 25 (25%)
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.
Good 20 (20%) – 22 (22%)
The student provides an accurate diagnostic impression with three (3) differentials.
Reflections demonstrate critical thinking.
Reflections contain 2 of the elements from the assignment directions.
Fair 18 (18%) – 19 (19%)
The student provides a vague, inaccurate, less than 3, or incomplete diagnostic impression with differentials.
Reflections are somewhat general or do not demonstrate critical thinking.
Reflections contain 1 of the required elements from the assignment directions.
Poor 0 (0%) – 17 (17%)
All or most of the discussion is inaccurate or missing. No diagnostic impression and less than 2 differential diagnoses.
Reflections are incomplete, inaccurate, or missing.
There are no Reflections elements from the assignment directions.
Comprehensive Psychiatric Evaluation documentation–
Excellent 23 (23%) – 25 (25%)
The response clearly, accurately, and thoroughly follows the Comprehensive Psychiatric Evaluation format to document the selected patient case.
Good 20 (20%) – 22 (22%)
The response accurately follows the Comprehensive Psychiatric Evaluation format to document the selected patient case.
Fair 18 (18%) – 19 (19%)
The response follows the Comprehensive Psychiatric Evaluation format to document the selected patient case, with some vagueness and inaccuracy.
Poor 0 (0%) – 17 (17%)
The response incompletely and inaccurately follows the Comprehensive Psychiatric Evaluation format to document the selected patient case.