S. Hicks 26, Male VS- 136/72, 98.6, 18, 100 %. No pain
1 Anxiety Disorder
2 Substance-Related & Addictive Disorder
3 Trauma & Stress-Related Disorder
Student Notes
Client is being seen for the first time with this organization. Client says that he has a hx of depression, anxiety, substance abuse, and ptsd. Says that in August of this year, he witnessed his mother and father being involved in a car accident that was fatal for his mother. Says the accident replays in his head repetitively. Says he has racing thoughts, poor concentration/focus, insomnia, paces all the time, cries intermittently, overwhelming feelings of sadness, feelings of guilt, and have panic attacks. Denies si/hi and a/v hallucinations. Eating fluctuates, but without any significant weight changes. Client says he is currently on suboxone-effective, and Klonopin- ineffective. Both medications were verified through Georgia PDMP. Says in the past he was addicted to oxycodone.
Objective
Mental Status Exam
Orientation: Person, place, and time
Behavior/Attitude: Pleasant, cooperative, anxious
Speech: easily understandable, hyperverbal
Thought Process: No obsessions, preoccupations, or phobia noted; No si/hi; no delusions or ideas of reference
Mood: depressed, anxious
Affect: Appropriate to mood
Memory: Intact immediate, intact remote
Concentration: fair to poor
Insight: fair
Judgment: fair
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.
