Subjective:?What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What is the duration and severity of their sympt

Scenario Note

Age: 14 years Sex: Female DOB: 1/21/2009

CAAP Admission Note

 

Chief Complaint

Patient: "I'm not suicidal"

Parent: "CAT team wants her to go to residential"

 

HPI

Quality: self injurious behavior/anxiety

Duration: months

Timing: acute on chronic

Severity: severe, interfering with safety of self

Context: precipitating stressor for admission partial response to medications

Modifying factors: medications, therapeutic milieu

Associated signs and symptoms: see HPI & MSE

HPI: Patient is a 14yo female with a prior psychiatric history of mood disorder who self-presents to crisis accompanied by her father for evaluation.

Upon interviewing today, patient is withdrawn, anxious appearing, thought process is linear and logical, thought content centered on her self-harm "I feel a bunch of emotions before I am doing it – I can be sad, I can be happy". Patient reports that in the last week her self-injurious behavior (cutting) has intensified. Patient has a superficial laceration on her neck, multiple lacerations on arms (she reports she uses glass). No intent to kill herself. Patient reports high anxiety levels. DFA. Patient compliant to her medication regime (zoloft 150mg, abilify 10mg, hydroxyzine as needed for anxiety). Patient stayed for 35 days in residential tx (she was discharged on 2nd September) – she does not want to go back. Pt started psychotherapy 5 months ago. Has an outpatient psychiatrist back in Key West.

Per patient:

Pt calm cooperative and pleasant during interview, and because she "knows what questions we are going to ask, immediately states "I just want to say, I am not suicidal!" She cites a dream she had recently where she placed her hand at the entrance to the underworld which both scared her and caused her to realize she would miss her dog if she killed herself. She has multiple other protective factors, however, including strict medication adherence, attending frequent outpatient appointments, supportive friends and family, and future plans to be either a therapist or neuroscientist. Pt admits to frequent episodes of SH however it is usually restricted to cutting or scratching her arms until this presentation. She used broken glass she found outside to lacerate her throat "that way I could see more blood" referring to the vascularity of the neck. Decision was not impulsive, reports she found the glass in the middle of the night, cut at 3pm the next day, then finally told her dad later that night because she felt guilty. Denies particular stressor prompting increasing SH and admits she did not attempt to use her normal coping strategies (writing horror stories) because she "didn't feel like it." She cuts primarily to feel release ie when she gets "panicky" and "feels like [she] has to." Pt admits to significant guilt about the SH due to how it makes her dad feel and the increased concern she caused in her CAT Team. She denies any plans to harm herself here in the hospital and promises to alert someone if she feels the urge to harm herself.

Pt reports a good relationship with her father, however states that he will yell when she cuts herself and sometimes slam doors both of which make the situation worse. Pt also endorses previous physical abuse at the hand of her mother including 5 instances of slapping and pulling her hair, DCF was not involved, last incident 2 years ago and pt no longer lives with her mother. She does see her 2-3 times a week however and mother lives with two other siblings. DCF REPORT FILED. Pt endorses avoiding anything her mother likes, increased startle response, and nightmares regarding the abuse. She admits that she has not explored either of these stressors with her therapist.

Pt does report daily symptoms of anxiety that last all day, primarily regarding her advanced classes. She also endorses increasing symptoms of depression including anhedonia, difficulty initiating sleep, guilt, decreased energy. Overall, she feels that zoloft has helped her with her depression and anxiety, notes that her dose was recently increased. She denies AVH, no evidence of mania or delusions. Admits to remote but minimal alcohol use, see below. Denies using other substances.

Per parent:

Father reports cutting began last December with admissions beginning in March. He denies any particular trigger or stressor of which he is aware, however does say she has a girlfriend who also cuts and because pt cannot help her, she feels guilty and cuts more. He reports that pt also cuts her abdomen and legs and had one incident of self harm while in a mental health facility (cut herself with sharp object she found in the bathroom). Father confirms pt's previous suicide attempt via OD on 250 pills of benadryl requiring significant medical attention. He reports her CAT team wants her to go to another residential facility due to this most recent event; however, he does not prefer this and would like to do everything possible before sending her. He feels like residential and hospital admissions are "breaking her," that his daughter thinks people are giving up on her when they send her away. He however will approve of whatever is best for his daughter. He signed a release of previous history documented by her CAT team and gives number for the therapist.

He gives verbal consent for naltrexone in addition to meds for which he has already signed in person when pt was admitted.

 

(from chart and updated as appropriate)

Past Psychiatric History

Inpatient treatment: recently 35 days in residential, multiple admissions: Nicklaus twice, Larkin once, Citrus 3-4 times, for SI and SH

Outpatient treatment: sees both psychiatrist and therapist in Key West regularly

Suicide History: 2 previous attempts, one less than 3 months ago took 250 pills benadryl

Past psychiatric medications: Lexapro dc'd due to inadequate response, vistaril inadequate response

Current psychiatric medications: Abilify 10mg daily, Zoloft 150mg daily (recently increased)

 

Medical History

Past medical history: denies

Past surgical history: denies

Seizures: denies

Loss of consciousness: denies

Traumatic brain injury: denies

Current nonpsychiatric medications: denies

Allergies

NKA

Substance Use History

Tobacco: denies

Alcohol: previous use, minimal. last drink 3-4months ago admits to drinking 4-5 drinks in a single sitting though frequency was only ever once every few months

Cannabis: denies

Cocaine: denies

Opioids: denies

Benzodiazepines: denies

Amphetamines: denies

Hallucinogens: denies

Detox/Rehab: denies

 

Trauma History

Physical: mother slapped her and pulled her hair approx 5 times, last time 2 years ago, no longer lives with mother though sees her 2-3x per week

Sexual: denies

Neglect: denies 

  

Family History

Mental illness: depression and anxiety in mother, grandfather, and brother

Suicide attempts: denies

Substance abuse: denies  

 

Developmental History

Birth history: vaginal

Developmental milestones:

walked at: early

talked at: early

toilet trained: early

Social: wnl however father notes pt more of an introvert, rather would stay in.

Psychosocial History

Born: Virginia

Raised: frequent moving, Key West for last 5 years

Siblings: 2 brothers 1 sister

Lives with: father /Parent are divorce

Relationship: friend she calls girlfriend, father unsure if romantic

Educational History

Grade: 9th, pt denies bullying

School: Key West High School

Grades: excellent, Father reports pt could recite the whole periodic table in 5th grade.

Suspensions: denies

Legal History

Legal guardian: father and mother joint custody

History of arrest: denies

Review of Systems

General: does not endorse fevers or weight change

HEENT: does not endorse sore throat or congestion

Cardiovascular: does not endorse chest pain or palpitations

Respiratory: does not endorse cough or wheezing

Gastrointestinal: does not endorse nausea, vomiting, or changes in bowel habits

Genitourinary: does not endorse dysuria or change in bladder habits

Neurological: does not endorse dizziness or numbness

MSK: does not endorse muscle or joint pain

 

Vital Signs

Temperature 36.9 (06:57)

Systolic Blood Pressure 113 (06:57)

Diastolic Blood Pressure 77 (06:57)

Pulse 75 (06:57)

SpO2 100 (06:57)

Respiratory Rate 18 (06:57)

  

Mental Status Exam

Appearance: well-groomed with good hygiene, significant number of superficial lacerations and scratches on bilateral arms of varying stages of healing, and across anterior neck

Behavior: calm and cooperative with interview

Orientation: awake, alert, oriented to person, location, date, situation

Speech: normal rate and rhythm, appropriate volume, spontaneous, comprehensible

Eye Contact: good

Motor Activity: no PMA/PMR/AIMs noted

Mood: "good"

Affect: reactive, full range

Thought Process: organized, goal directed

Thought Content: no delusions, preoccupations, obsessions, compulsions, or phobias elicited

Suicidal Ideation/Thought/Intent/Plan: denies

Homicidal Ideation/Thought/Intent/Plan: denies

Perceptual Disturbances: denies AVTOG hallucinations

Insight/Judgment: good/poor

Attention/Concentration: good/good

Memory: grossly intact

Scales

 

Differential

DSM-5 Diagnosis:

Depressive Disorder Unspecified F32.9

Anxiety Disorder Unspecified F41.9

Unspecified mood [affective] disorder (F39)

1. Occupational/Recreational/Activity Therapy: will participate

2. School: will attend

3. Scales: n/a

4. Information: previous records, school information

5. Studies to be ordered: n/a

6. Precautions: Line of sight

7. Individual sessions: psychoeducation, safety, coping skills

8. Family sessions: psychoeducation, safety, length of stay

9. Medications: continue Abilify 10mg QHS and zoloft 150mg daily. Start Naltrexone 25mg PO daily

Medication List

Active Medications

Ordered

acetaminophen: 325 mg, 1 tab, ORAL, Q6H, PRN: Pain – Mild.

ARIPiprazole: 10 mg, 1 tab, ORAL, BEDTIME.

diphenhydrAMINE: 50 mg, 1 cap, ORAL, BEDTIME, PRN: Insomnia.

hydrOXYzine: 50 mg, 1 cap, ORAL, Q6H, PRN: Anxiety.

melatonin: 5 mg, 1 tab, ORAL, BEDTIME, PRN: as needed for insomnia.

naltrexone: 25 mg, 0.5 tab, ORAL, DAILY.

sertraline: 150 mg, 3 tab, ORAL, DAILY.

Documented

ARIPiprazole: 106.

sertraline: 106.

Medications Inactivated in the Last 72 Hours

No medications found.

10. Aftercare planning: medication management, family therapy, continue with services provided by CAT team

11. Estimated length of stay: tbd, likely Fri or Sat

· State 3–4 objectives for the presentation that are targeted, clear, use appropriate verbs from Bloom’s taxonomy, and address what the audience will know or be able to do after viewing.

· Present the full complex case study. Include chief complaint; history of present illness; any pertinent past psychiatric, substance use, medical, social, family history; most recent mental status exam; current psychiatric diagnosis including differentials that were ruled out; and plan for treatment and management.

· 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. 

· Pose three questions or discussion prompts, based on your presentation, that your colleagues can respond to after viewing your video.

· Be succinct in your presentation, and do not exceed 8 minutes. Specifically address the following for the patient, using your SOAP note as a guide.

· Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life?

· Objective: What observations did you make during the psychiatric assessment? 

· Assessment: Discuss their mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses and why you chose them. List them from highest priority to lowest priority. What was your primary diagnosis, and why? Describe how your primary diagnosis aligns with  DSM-5 -TR diagnostic criteria and is supported by the patient’s symptoms.

· Plan: What was your plan for psychotherapy (include one health promotion activ

Collepals.com Plagiarism Free Papers

Are you looking for custom essay writing service or even dissertation writing services? Just request for our write my paper service, and we'll match you with the best essay writer in your subject! With an exceptional team of professional academic experts in a wide range of subjects, we can guarantee you an unrivaled quality of custom-written papers.

Get ZERO PLAGIARISM, HUMAN WRITTEN ESSAYS

Why Hire Collepals.com writers to do your paper?

Quality- We are experienced and have access to ample research materials.

We write plagiarism Free Content

Confidential- We never share or sell your personal information to third parties.

Support-Chat with us today! We are always waiting to answer all your questions.