Psychiatric Note

CASE STUDY – WEEK # 7

Name: Mrs. L.R.

Gender: female Age: 28 years old T- 97.6 P- 87 R 18 161/86 Ht 5’6 Wt 217 lbs

C.C. “I’m feeling sad and anxious every day, with no energy, crying constantly and at night I’s sleeping only few hours. I don’t want to spend time with my newborn, my 4 years old daughter or my husband. Lately I feel like people is looking at me constantly”

Background: Recently had her second child five months ago. Currently married; stay at home mother after working in private firm for 7 years.

Grew up with both parents, mother with hx. of depression and hypothyroidism, father with hx. of hypertension and myocardial infarction (MI) at 62 y/o, both retired.

Sister lives in Orlando, FL with hx. of depression and diabetes, single no children and brother in last year of high school, no previous medical or psychiatric history.

Completed education through bachelor’s level, studying accounting and business administration. No previous suicidal gestures; has uncle who committed suicide via GSW. She denied drugs/alcohol; uncle was opioid abuser.

Hx of HTN-prescribed labetalol 100mg twice daily, admits to missing doses due to forgetting. No legal hx. Allergies: lidocaine and penicillin.

 

ASSIGNMENT INSTRUCTIONS:

· Select a patient that you examined during the last 2 weeks who presented with a disorder  (See above Case study – Week # 7)

 

· Conduct a Comprehensive Psychiatric Evaluation on this patient and use the template provided to complete the assifment. There is also a completed exemplar document that you can see an example of the types of information a completed evaluation document should contain. ( see attached documents)

 

· Include at least five (5) scholarly resources to support your assessment and diagnostic reasoning.

 

· Report normal diagnostic results as the name of the test and “normal” (rather than specific value). Abnormal results should be reported as a specific value.

 

· 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?