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Behavior/Attitude: Pleasant, cooperative, guarded, paranoid, restless, anxious, withdrawn, disorganized, avoidant, resistant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.
