Depression & Anxiety Case Study

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DescriptionUnit
4 Assignment – Depression & Anxiety Case StudySubmit AssignmentDue Apr 4 by 11:59pmPoints 100Submitting a text entry box, a website url, a media
recording, or a file uploadInstructionsComplete a full intake on this patient and then develop a
treatment plan using the template offered.Patient HistoryThe patient is a 59-year-old married woman
with 5 grown childrenShe is moderately overweight (BMI 30) and was diagnosed with
non-insulin-dependent diabetes 10 years ago; she is fairly well managed on an
oral hypoglycemic medication (glipizide 10 mg twice per day)Two years ago, the patient experienced 2 tremendous stressors:
her oldest child developed leukemia (now in remission), and her
mother and father both passed awayShe suffered a significant and impairing major depressive
episode that went untreated until recentlyThis was her fifth episode of depression; she experienced 2
major depressive episodes as a teenager, and she developed postpartum
depression and anxiety following the births of 2 of her
childrenFour months ago, after she was too fatigued to get out of
bed, she sought treatment for the first time in her lifeAfter receiving education and support from her clinician, she
reluctantly agreed to take Paxil 30 mg/dayThe patient has experienced a near-complete resolution of her
symptoms in the last 6 months; however, she has developed side
effects and wants to discontinue the medicationSpecifically, she has increased appetite and has correspondingly
gained 7 pounds in the last 4 months, with an increase in HgA1c of 1 full
percentage pointShe also reports excess daytime sedation and anorgasmia (very
unusual for her)What options can you offer to manage these side effects?
Be specificWhat education should you give the patient about stopping this
medication abruptly?What is your treatment plan?Assignment File(s)·Case Study TemplateInitial Psychiatric SOAP Note TemplateThere are different ways in which to complete a Psychiatric
SOAP (Subjective, Objective, Assessment, and Plan) Note. This is a template
that is meant to guide you as you continue to develop your style of SOAP in the
psychiatric practice setting.CriteriaClinical NotesInformed ConsentInformed
consent given to patient about psychiatric interview process andpsychiatric/psychotherapytreatment.Verbal and Written consent obtained.Patienthasthe ability/capacity to respond and appears tounderstandthe risk, benefits, and (Will review additional consent during
treatment plan discussion)SubjectiveVerify PatientName:DOB:Minor:Accompanied
by:Demographic:Gender Identifier Note:CC:HPI:Pertinent
history in record and from patient:XDuring
assessment: Patient describes their moodas X and indicated it has gotten
worse in TIME.Patient
self-esteem appearsfair,no reported feelings
of excessive guilt,no reported anhedonia,does not
report sleep disturbance,does not report change in appetite,does not report libido disturbances,does not report change in
energy,no reported changes in concentration or memory.Patientdoes not
report increased activity, agitation, risk-taking behaviors, pressured
speech, or euphoria.Patientdoes not report excessive fears, worries or panic attacks.Patientdoes not
report hallucinations, delusions, obsessions or compulsions.Patient’sactivity level, attention
and concentration were observed to be within normal limits.  Patientdoes not reportsymptoms of eating disorder. There isno recent weight loss or
gain. Patientdoes not reportsymptoms of a characterological nature.SI/
HI/ AV:Patient currentlydeniessuicidal
ideation,deniesSIBx,denieshomicidal ideation,deniesviolent
behavior,deniesinappropriate/illegal behaviors.Allergies:NKDFA.(medication & food)Past Medical Hx:Medical
history:Denies
cardiac, respiratory, endocrine and neurological issues, including history
head injury.Patientdenies history of
chronic infection, including MRSA, TB, HIV and Hep C.Surgical historyno surgical history reportedPast Psychiatric Hx:Previous
psychiatric diagnoses:none reported.Describesstablecourse of illness.Previous medication trials:none reported.Safety
concerns:History of Violenceto Self:none reportedHistory of Violence to Others:none
reportedAuditory
Hallucinations:Visual
Hallucinations:Mental
health treatment historydiscussed:History of outpatient treatment:not reportedPrevious psychiatric hospitalizations:not reportedPriorsubstance
abuse treatment:not
reportedTrauma history:Clientdoes not
report history of trauma including abuse, domestic violence, witnessing
disturbing events.Substance Use:Clientdenies use or
dependence on nicotine/tobacco products.Clientdoes not report abuse
of or dependence on ETOH, and other illicit drugs.Current
Medications:No current medications.(Contraceptives):Supplements:Past Psych Med Trials:Family Medical Hx:Family Psychiatric Hx:Substance
useSuicidesPsychiatric diagnoses/hospitalizationDevelopmental diagnosesSocial
History:Occupational
History: currentlyunemployed.Denies previous occupational hxMilitary
service History:Denies previous military hx.Education
history:completed
HS and vocational certificateDevelopmental
History:no significant details reported.(Childhood History)Legal
History:no reported/known legal issues,no reported/known conservator or guardian.Spiritual/Cultural
Considerations:none
reported.ROS:Constitutional:No report of fever or weight loss.Eyes:No report of acute vision changes or eye pain.ENT:No report of hearing changes or difficulty swallowing.Cardiac:No report of chest pain, edema or orthopnea.Respiratory:Denies dyspnea, cough or wheeze.GI:No report of abdominal pain.GU:  No report of dysuria or hematuria.Musculoskeletal:No report of joint pain or swelling.Skin:  No report of rash, lesion, abrasions.Neurologic:No report of seizures, blackout, numbness or focal weakness.  Endocrine:No report of
polyuria or polydipsia.Hematologic:No report of blood clots or easy bleeding.Allergy:No report of hives or allergic reaction.Reproductive:No report of significant issues. (females: GYN hx;
abortions, miscarriages, pregnancies, hysterectomy, PCOS, etc…)Verify
Patient:Name, Assignedidentificationnumber (e.g.,
medical record number), Date of birth, Phone number, Social security number, Address,
Photo.Include demographics, chief complaint,
subjective information from the patient, names and relations of others
present in the interview.HPI:, Past Medical and Psychiatric History,Current Medications, Previous Psych Med
trials,Allergies.Social History, Family History.Review of Systems (ROS) – if ROS is
negative, “ROS noncontributory,” or “ROS negative with the exception of…”ObjectiveVital Signs:StableTemp:BP:HR:R:O2:Pain:Ht:Wt:BMI:BMI Range:LABS:Lab findingsWNLTox screen:NegativeAlcohol:NegativeHCG:N/APhysical
Exam:MSE:Patient
iscooperativeandconversant,
appearswithoutacute distress, andfully oriented x 4. Patient is dressedappropriately for age and
season.Psychomotor activity appearswithin normal.Presents
withappropriateeye contact,euthymicaffect -full,even,congruentwith reported mood of “x”.Speech:spontaneous,normalrate,appropriatevolume/tone withno problems expressing self.TC:no abnormalcontent elicited,deniessuicidal ideation anddenieshomicidal
ideation.
Process appearslinear,coherent,goal-directed.Cognitionappears grossly intactwithappropriateattention span & concentration andaveragefund of knowledge.Judgment
appearsfair. Insight appearsfairThe patientis ableto articulate needs,ismotivated
for compliance and adherence to medication regimen. Patientiswillingand ableto
participate with treatment, disposition, and discharge planning.This is where the “facts” are located.Vitals,**Physical Exam (if performed, will not be performed
every visit in every setting)Include relevant labs, test results, and
Include MSE, risk assessment here, and psychiatric screening measure results.AssessmentDSM5 Diagnosis: with ICD-10 codesDx:-Dx:-Dx:-Patienthasthe ability/capacity appears to
respond to psychiatricmedications/psychotherapyand appears tounderstandthe need formedications/psychotherapyandiswilling to maintain adherent.Reviewed potential risks & benefits, Black Box
warnings, and alternatives including declining treatment.Instruction Files4-2casestudy.docx41.3 KB

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