AdmiralKoupreyMaster573
Mrs. TP voluntarily presents today with severely depressed mood…
Mrs. TP voluntarily presents today with severely depressed mood x 2 months that began after the death of her dog. She feels depressed more days than not, has crying spells 6 out of 7 days. No longer finds pleasure in gardening and has been written up at work due to missing work. She denies SI/HI. Reports feeling anxious daily with difficulty falling and staying asleep. Mrs. TP reports feeling tired daily and fatigue, with psychomotor retardation of just lying-in bed. She has had an increase in appetite and gained 15 lbs. in last 2 month. When she is having a depressed day, she attempts to think about her grandchildren, but this has not helped, she has avoided the dog park because it makes her depression worse. She denies previous episodes of depression.
INTRODUCTION
What is the s/s present, what is the trigger/precipitating event, how often and how severe, what makes s/s better what makes it worse? I realize in the case study you may not be given the how often. That is when you insert below the HPI the following information was missing… This demonstrates that you understand the key components of an HPI.
The psychosocial history is not just what is in the background document there is more information in that background document than what belongs in the psychosocial assessment you will need to be able to pick out from that background document what belongs in the psychosocial what belongs in the medical history, past history etc…
You cannot say the Physical exam is Not applicable. A exam of some sort is always applicable. What is the client’s v/s, ht/wt, BMI. Every case study had a set of vital signs in the background information. What can you see during the interview? Is the client’s skin pale? Was a tremor present? Any acute distress?? Keep in mind when you are practicing many insurance companies require at least 3 points of vital signs for payment of services. It is best to get in the habit of documenting this now.
Diagnostic results: If you are given none in the case study tell me what you would order, why, and what evidence supports it. It maybe blood work or CT of the head etc. Additionally, what assessment/screening tool would you use for this patient? Do not give every possible one but what you would order why, and what evidence supports it. For example, if the patient expresses SI a suicide scale/assessment would be desirable.
MSE: you must give the MSE in paragraph form. The exemplar in you course is helpful but page 213 of Kaplan & Saddock gives more detail and helpful information.
Differential Diagnosis: I want to see that you can connect the presenting s/s to the diagnostic criteria. You can give background information about the diagnosis, but you must demonstration that you can justify the diagnosis with the presentation and criteria. example” Mr.A.W. meets criteria A of depression as evidence by ……..
Be sure you start your assignment with Title page and an introduction.
