Mildred is a 45-year-old married female with three children. She presents to the clinic with complaints of fatigue and difficulty sleeping. She states she w
PICK ONE
Mildred is a 45-year-old married female with three children. She presents to the clinic with complaints of fatigue and difficulty sleeping. She states she wants to get a good night’s sleep and is requesting a prescription to help her sleep. Mildred tells you she is awake off and on during the night, frequently thinking about her husband’s recent layoff from construction work and the effect this is having on the family. She lies down often during the day and has been so fatigued that she took some time off from work during the last two weeks. She is tearful at times during the visit and looks sad and anxious. On further discussion, she says she feels overwhelmed, helpless, and anxious. She tells you about an episode where she felt her heart beating rapidly, had difficulty catching her breath, felt she was going to have a heart attack, and became frightened until her husband was able to help calm her down. She is not eating as much as usual, and when she reads the newspaper, she does not remember what she has read.
Kylie, a 24-year-old female patient, comes to your office for a refill of her allergy medication. Before going into the room, you note that her Patient Health Questionnaire – Depression (PHQ-9) score is 20, and that she is not currently on any medication for depression. When you enter the room, you notice that Kylie is easily startled, and she is sitting in the corner of the room very close to the wall.
Dale, a 40-year-old construction worker, lost his 4-year-old daughter in a car accident six months ago, in which his sister was driving and he was a passenger. He is at this visit for a follow-up of a shoulder injury sustained last month. You notice that he has lost about eight pounds since his last visit, and he is somewhat disheveled in his appearance. Dale has not been back to work, and has not been able to get into a car since the accident. Before going into the room, your nurse pulled you aside to let you know that the patient was very rude to the front office staff, and was also rude to her while he was being processed for his visit. This is not Dale’s usual behavior.
Case Study Chosen: (List what case you have chosen)
Demographics: Age/Gender
SUBJECTIVE
• CC: • HPI: (As listed from Case Study Information) • Subjective: (What questions will you ask? Must be listed by System, ONLY as it
pertains to Chief Complaint/HPI. Should NOT be all systems or full head to toe unless pertinent).
OBJECTIVE
General:
• VS BP, HR, RR, Weight, Height, BMI • Physical Exam Elements: (Must be listed by System, ONLY as it pertains to Chief
Complaint/HPI. Should NOT be all systems or full head to toe unless pertinent.) • POC Testing (any Point of Care (POC) testing specifically performed in the office):
What tests (if any) did you perform during the visit (urine dip, rapid strep, urine pregnancy test, Glucose finger-stick, etc.)? Leave blank if none.
ASSESSMENT
• Working Diagnosis: (Must include ICD 10) • Differential Diagnosis:
PLAN
• Diagnostic studies: If any, will be ordered (Labs, X-ray, CT, etc.). Only include if you will be ordering for your patient. Remember the importance of appropriate resource utilization. Remember you are managing this patient in the CLINIC setting, NOT THE HOSPITAL.
• Treatment: Must include full Sig/Order for all prescriptions and OTC meds (Name of medication, dosage, frequency, duration, number of tabs, number of refills). CANNOT only list drug class. Should follow evidence-based guidelines.
• Referrals: If Applicable
• Education: • Health maintenance: • RTC:
Differential Signs/Symptoms Gold Standard Diagnostics
Gold Standard Treatment
Ex: PTSD
Flashbacks, nightmares, intrusive thoughts, avoidance of reminders of trauma, agoraphobia, sleep disturbance and hypervigilance, feelings of detachment.
Clinician- Administered PTSD Scale (CAPS-5)
First-line treatment with a trauma- focused psychotherapy such as eye movement desensitization and reprocessing (EMDR). In individuals with comorbid disorders (ex., depression, psychosis) that affect the person’s ability to work in trauma-focused therapy (ex., concentration, motivation), treat with pharmacologic management; SSRI first line such as sertraline or paroxetine.
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