Write Case With 62 Years Old Female Patient With Dx Major Depress Disorder.
MRU PMHNP Clinical Write-Up
Student Name:
Typhon Case #
Semester/Year:
Course:
Chief Complaint
| What brought you here today…? (Put this in quotes.) | “ |
History of Present Illness
| Depression symptoms: Can you describe your depression symptoms? What makes the depression better, what makes the depression worse? Does the depression, come and go? | |
| Anxiety: Does the anxiety come and go or is there all the time? Does anything make the anxiety worse or better? Do you go into panic? If so, how often and how long does it usually last? | |
| Mood swings: Do your moods go up and down? If so, can you tell me more about a typical mood swing? |
|
| Anger/irritability: Do you get angry more than you should? How do you act when you get angry? | |
| Attention and focus: Do you have trouble concentrating or staying on track? | |
| Current self-harm, suicidal/homicidal ideations: Do you currently or have you recently thought about hurting yourself? If so, do you have a plan of hurting yourself? | |
| Hallucinations: Do you ever hear or see anything that other people may not hear and/or see? | |
| Paranoia: Do you feel like people are talking about your or following you? | |
| Sleep: Do you have trouble falling or staying asleep? How long does it take you to fall asleep? Once you get to sleep, do you stay asleep all night or are you up and down throughout the night? |
Past Psychiatric History
| At what age did the mood symptoms start? | |
| Do you have a previous psychiatric diagnosis? If so, what age and what was going on (if anything) around the time of the diagnosis? | |
| Where there any environmental factors that could have contributed to the moods? For example, divorce, death in the family, etc. | |
| Any previous treatment and if so, what was it and did it work? List any previous psychiatric medications have been tried and why the medication was stopped. |
Family History
| Include parents, siblings, grandparents if applicable/known; pertinent mental health history. |
Personal/Social History
| Education, marital status, occupation, work history, and legal history |
Substance Abuse History
| Do you currently or in the past used any illegal drugs? If so, what did you use? If currently using drugs, how much do you use? When was the last time you used? | |
| Do you currently or in the past had an issue with alcohol abuse? If so, when was the last time you drank? Do you ever pass out when you drink? Has your drinking been a problem for you in the past? | |
| Do you currently smoke cigarettes or vape? | |
| Do you smoke marijuana? |
Medical History
| Medical problems | |
| Previous surgeries |
Mental Status Exam
Appearance and Behavior
| Appearance: Gait, posture, clothes, grooming | |
| Behaviors: mannerisms, gestures, psychomotor activity, expression, eye contact, ability to follow commands/requests, compulsions | |
| Attitude: Cooperative, hostile, open, secretive, evasive, suspicious, apathetic, easily distracted, focused, defensive | |
| Level of consciousness: Vigilant, alert, drowsy, lethargic, stuporous, asleep, comatose, confused, fluctuating | |
| Orientation: “What is your full name?” “Where are we at (floor, building, city, county, and state)?” “What is the full date today (date, month, year, day of the week, and season of the year)?” | |
| Rapport |
Speech
| Quantity descriptors: talkative, spontaneous, expansive, paucity, poverty. | |
| Rate: fast, slow, normal, pressured | |
| Volume (tone): loud, soft, monotone, weak, strong | |
| Fluency and rhythm: slurred, clear, with appropriately placed inflections, hesitant, with good articulation, aphasic |
Affect and Mood
| Mood (how the person tells you they’re feeling): “How are you feeling?” | |
| Affect (what you observe): appropriateness to situation, consistency with mood, congruency with thought content
· Fluctuations: labile, even, expansive · Range: broad, restricted · Intensity: blunted, flat, normal, hyper-energized · Quality: sad, angry, hostile, indifferent, euthymic, dysphoric, detached, elated, euphoric, anxious, animated, irritable |
|
| Congruency: congruent or not congruent mood? |
Perception
| Paranoia | |
| Auditory hallucinations | |
| Visual hallucinations |
Thought Content
| Suicidal | |
| Homicidal | |
Delusions (erotomanic, grandiose, jealous, persecutory, and somatic themes?)
|
|
| If not a delusion, then could it be an overvalued idea (an unreasonable and sustained belief that is maintained with less than delusional intensity (i.e. – the person is able to acknowledge the possibility that the belief is false)? | |
| Ideas of Reference (IOR): everything one perceives in the world relates to one’s own destiny (e.g., thinking the computer or TV is sending messages or hints). | |
| First rank symptoms: auditory hallucinations, thought withdrawal, insertion and interruption, thought broadcasting, somatic hallucinations, delusional perception, and feelings or actions experienced as made or influenced by external agents | |
| What is actually being said? Does the content contain delusions? | |
| Are the thoughts ego-dystonic or ego-syntonic? |
Thought Form/Process
| What is the logic, relevance, organization, flow, and coherence of thought in response to general questioning during the interview? | |
| Descriptors: linear, goal-directed, circumstantial, tangential, loose associations, clang associations, incoherent, evasive, racing, blocking, perseveration, neologisms. |
Cognition
| Cognitive testing | |
| Education level |
Insight
| What is their understanding of the world around them and their illness? | |
| Are they able to do reality-testing (i.e., are they able to see the situation as it really is)? | |
| Are they help-seeking? Help-rejecting? |
Judgement
| What have their actions been? Have they done anything to put themselves or other people at harm? | |
| Are they behaving in a way that is motivated by perceptual disturbances or paranoia? | |
| What is your confidence in their decision making? |
Medications
| Medical medications (list) | |
| Psychiatric medications (list) |
Psychiatric Medication
Use this template of this table for each medication. Try to use your own words. For example, how would you explain this information to them or their family?
| Brand/generic name | |
| Dose at the time of visit | |
| Starting dose | |
| How does this medication work? | |
| Major side effects | |
| Is this medication FDA approved for why the person is using this medication? | |
| Patient education | |
| Medication class |
Psychiatric Diagnosis
| Current diagnosis | |
| DSM-5 symptom criteria for each diagnosis (write out DSM-5 symptom criteria) | |
| Did they display/state any symptoms that match the diagnosis? |
Billing/Coding
| ICD 10 Code | |
| Billing Code |
Treatment Plan
| Medication changes made during visit | |
| Clinical impression | |
| Recommended therapy/support sources for person and the reason why | |
| Next visit scheduled |
Clinical Write-Up: Major Depressive Disorder
Student Name:
Write Up #:
Typhon Case #:
Semester/Year:
Course:
Chief Complaint
“What brought you here today?”
“I’ve been feeling extremely down and hopeless for a long time. I can’t seem to enjoy anything anymore, and I don’t have the energy to do anything.”
History of Present Illness
Depression Symptoms
Can you describe your depression symptoms?
“I feel sad and empty most days. I cry a lot and have no interest in activities I used to enjoy.”
What makes the depression better?
“Nothing really makes it better.”
What makes the depression worse?
“Stress and being alone make it worse.”
Does the depression come and go?
“It’s constant, but some days are worse than others.”
Anxiety
Does the anxiety come and go or is it there all the time?
“It comes and goes.”
Does anything make the anxiety worse or better?
“Stress makes it worse; being around friends sometimes helps.”
Do you go into panic? If so, how often and how long does it usually last?
“I have panic attacks a few times a month, lasting about 15-20 minutes.”
Mood Swings
Do your moods go up and down? If so, can you tell me more about a typical mood swing?
“Yes, I can be fine one moment and then very irritable or sad the next.”
Anger/Irritability
Do you get angry more than you should?
“Yes, I get angry over small things.”
How do you act when you get angry?
“I tend to shout or isolate myself.”
Attention and Focus
Do you have trouble concentrating or staying on track?
“Yes, I find it hard to focus on tasks or conversations.”
Self-Harm/Suicidal Ideations
Do you currently or have you recently thought about hurting yourself? If so, do you have a plan of hurting yourself?
“I’ve thought about it, but I don’t have a plan.”
Hallucinations
Do you ever hear or see anything that other people may not hear and/or see?
“No, I haven’t experienced that.”
Paranoia
Do you feel like people are talking about you or following you?
“No, I don’t feel that way.”
Sleep
Do you have trouble falling or staying asleep? How long does it take you to fall asleep?
“I have trouble falling asleep; it takes me about an hour.”
Once you get to sleep, do you stay asleep all night or are you up and down throughout the night?
“I wake up several times during the night.”
Past Psychiatric History
At what age did the mood symptoms start?
“Around 50 years old.”
Do you have a previous psychiatric diagnosis? If so, what age and what was going on (if anything) around the time of the diagnosis?
“Yes, I was diagnosed with depression at 52 after my husband passed away.”
Were there any environmental factors that could have contributed to the moods? For example, divorce, death in the family, etc.
“The death of my husband was a major factor.”
Any previous treatment and if so, what was it and did it work? List any previous psychiatric medications have been tried and why the medication was stopped.
“I’ve tried fluoxetine and sertraline; they helped a bit but had too many side effects.”
Family History
Include parents, siblings, grandparents if applicable/known; pertinent mental health history.
“My mother had depression, and my brother has anxiety.”
Personal/Social History
Education, marital status, occupation, work history, and legal history
“I have a high school diploma. I’m widowed and used to work as a teacher. No legal history.”
Substance Abuse History
Do you currently or in the past used any illegal drugs? If so, what did you use? If currently using drugs, how much do you use? When was the last time you used?
“No illegal drug use.”
Do you currently or in the past had an issue with alcohol abuse? If so, when was the last time you drank? Do you ever pass out when you drink? Has your drinking been a problem for you in the past?
“I drink occasionally, but it’s never been a problem.”
Do you currently smoke cigarettes or vape?
“No.”
Do you smoke marijuana?
“No.”
Medical History
Medical problems
“Hypertension, hypothyroidism.”
Previous surgeries
“Hysterectomy 10 years ago.”
Mental Status Exam
Appearance and Behavior
Appearance:
“Well-groomed, posture slouched, casual clothing.”
Behaviors:
“Limited eye contact, slow psychomotor activity, follows commands.”
Attitude:
“Cooperative but apathetic.”
Level of consciousness:
“Alert.”
Orientation:
“Correctly identified name, location, and date.”
Rapport:
“Established good rapport despite initial hesitation.”
Speech
Quantity descriptors:
“Poverty of speech.”
Rate:
“Slow.”
Volume (tone):
“Soft.”
Fluency and rhythm:
“Clear, with appropriately placed inflections.”
Affect and Mood
Mood (how the person tells you they’re feeling):
“Depressed.”
Affect (what you observe):
“Flat affect, consistent with reported mood.”
Perception
Paranoia:
“None reported.”
Auditory hallucinations:
“None reported.”
Visual hallucinations:
“None reported.”
Thought Content
Suicidal:
“Occasional thoughts but no plan.”
Homicidal:
“None.”
Delusions:
“None.”
Ideas of Reference (IOR):
“None.”
Thought Form/Process
Descriptors:
“Linear, goal-directed.”
Cognition
Cognitive testing:
“Intact for age and education level.”
Insight
Understanding of illness:
“Adequate insight into her depression.”
Reality-testing:
“Intact.”
Help-seeking:
“Motivated for treatment.”
Judgment
Actions:
“Good judgment, no harmful actions reported.”
Decision making:
“Confident in decision-making ability.”
Medications
Medical Medications
- Lisinopril: 10 mg daily for hypertension.
- Levothyroxine: 50 mcg daily for hypothyroidism.
Psychiatric Medications
- Sertraline: 50 mg daily, stopped due to side effects.
- Fluoxetine: 20 mg daily, stopped due to side effects.
Psychiatric Diagnosis
Current diagnosis:
Major Depressive Disorder (MDD)
DSM-5 symptom criteria for MDD:
- Depressed mood most of the day, nearly every day.
- Markedly diminished interest or pleasure in all, or almost all, activities.
- Significant weight loss or weight gain, or decrease or increase in appetite.
- Insomnia or hypersomnia nearly every day.
- Psychomotor agitation or retardation nearly every day.
- Fatigue or loss of energy nearly every day.
- Feelings of worthlessness or excessive guilt.
- Diminished ability to think or concentrate, or indecisiveness.
- Recurrent thoughts of death, suicidal ideation without a specific plan, or a suicide attempt.
Did they display/state any symptoms that match the diagnosis?
“Yes, the patient displayed most of the symptoms outlined in the DSM-5 criteria for MDD.”
Billing/Coding
- ICD 10 Code: F32.9 (Major depressive disorder, single episode, unspecified)
- Billing Code: 99213 (Established patient office visit, moderate complexity)
Treatment Plan
Medication changes made during visit:
Initiate escitalopram 10 mg daily.
Clinical impression:
The patient is experiencing symptoms consistent with Major Depressive Disorder, requiring pharmacological and therapeutic intervention.
Recommended therapy/support sources:
- Cognitive Behavioral Therapy (CBT) to address negative thought patterns.
- Support group for individuals experiencing bereavement.
Next visit scheduled:
Follow-up in 4 weeks to assess medication efficacy and side effects.