RUBRIC:
- Time
- Discuss Subjective data:• Chief complaint• History of present illness (HPI)• Medications• Psychotherapy or previous psychiatric diagnosis• Pertinent histories and/or ROS
- Discuss Objective data:• Physical exam documentation of systems pertinent to the chief complaint, HPI, and history• Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses
- Discuss results of Assessment:• Results of the mental status examination• Provide a minimum of three possible diagnoses in order of highest to lowest priority and explain why you chose them. What was your primary diagnosis and why? Describe how your primary diagnosis aligns with DSM-5 diagnostic criteria and is supported by the patient’s symptoms.
- Discuss treatment Plan:• A treatment plan for the patient that addresses chosen FDA-approved psychopharmacologic agents and includes alternative treatments available and supported by valid research. The treatment plan includes rationales, a plan for follow-up parameters, and referrals. The discussion includes one social determinant of health according to the HealthyPeople 2030, 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.
- Reflect on this case. Discuss what you learned and what you might do differently.
- Focused SOAP Note documentation
- Presentation style.
CASE STUDY TO USE FOR THE ASSIGNMENT:
-Hospital or Specialty Care Facility
Age: Adolescent (13-17 years)
Sex: Female
Visit InformationStudent Level of Function: Joint Care – Level 3
Category of Care: Direct Patient Care
Practice Management
Type of visit: Consultation
Diagnosis
1 Anxiety Disorder
2 Impulse-Control Disorder
Student Notes
9/29/2022 Patient # 35 16-year-old female who presents for assessment. She believes that she has \”anger and severe anxiety with mood swings.\” She is worried about her poor relationship with her mother and that she is not open enough with her and feels uncomfortable telling her how she feels. She states that there was an argument where she punched the door, threw a chair at her mother, poured soda on the ground, and left after her mom kicked her out.
She states that her violence was out of frustration. She states that she sometimes gets in trouble at school and once suspended for illicit drug use. Medications Lexapro and Vistaril for anxiety with CBT and family therapy ordered. Follow up in two weeks.