MRU PMHNP Clinical Write-Up

### MRU PMHNP Clinical Write-Up

**Student Name:**
[Your Name]

**Write Up #:**
1

**Typhon Case #:**
[Case Number]

**Semester/Year:**
Summer 2024

**Course:**
[Course Name]

—

### Chief Complaint
“What brought you here today…?”
“I’ve been feeling really down and anxious, and I think I need help.”

—

### History of Present Illness
**Depression Symptoms:**
– Can you describe your depression symptoms? “I feel sad and hopeless most days. I have no energy and can’t enjoy anything.”
– What makes the depression better? “Nothing really helps, maybe sleeping.”
– What makes the depression worse? “Being alone and thinking too much.”
– Does the depression come and go? “It’s there almost all the time.”

**Anxiety:**
– Does the anxiety come and go or is it there all the time? “It comes and goes, but it’s getting worse.”
– Does anything make the anxiety worse or better? “Stress makes it worse; sometimes deep breathing helps a bit.”
– Do you go into panic? If so, how often and how long does it usually last? “Yes, maybe once a week. It lasts for about 10-15 minutes.”

**Mood Swings:**
– Do your moods go up and down? “Yes, sometimes I feel better, but then I feel terrible again.”
– Can you tell me more about a typical mood swing? “I can go from feeling okay to crying and feeling hopeless in a matter of hours.”

**Anger/Irritability:**
– Do you get angry more than you should? “Yes, small things set me off.”
– How do you act when you get angry? “I shout and sometimes throw things.”

**Attention and Focus:**
– Do you have trouble concentrating or staying on track? “Yes, I can’t focus on anything for long.”

**Current Self-Harm, Suicidal/Homicidal Ideations:**
– Do you currently or have you recently thought about hurting yourself? “Yes, I’ve thought about it.”
– If so, do you have a plan of hurting yourself? “I’ve thought about overdosing on my medication.”

**Hallucinations:**
– Do you ever hear or see anything that other people may not hear and/or see? “No, I don’t.”

**Paranoia:**
– Do you feel like people are talking about you or following you? “Sometimes I feel people are talking about me behind my back.”

**Sleep:**
– Do you have trouble falling or staying asleep? “Yes, it takes me hours to fall asleep.”
– How long does it take you to fall asleep? “About 2-3 hours.”
– 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 a night.”

—

### Past Psychiatric History
– At what age did the mood symptoms start? “In my early twenties.”
– Do you have a previous psychiatric diagnosis? “Yes, I was diagnosed with major depressive disorder at 25.”
– Were there any environmental factors that could have contributed to the moods? “My parents divorced when I was 18.”
– Any previous treatment and if so, what was it and did it work? “I’ve been on and off different antidepressants; they help a bit but never fully.”
– List any previous psychiatric medications have been tried and why the medication was stopped. “Prozac (stopped due to side effects), Zoloft (didn’t feel it was effective).”

—

### Family History
– Mother: Depression
– Father: Alcoholism
– Siblings: None known
– Grandparents: Paternal grandmother had anxiety disorder

—

### Personal/Social History
– **Education:** Bachelor’s degree in Business Administration
– **Marital Status:** Single
– **Occupation:** Marketing Specialist
– **Work History:** Stable job history, currently employed
– **Legal History:** No legal issues

—

### Substance Abuse History
– Do you currently or in the past used any illegal drugs? “I used marijuana in college, but not anymore.”
– Do you currently or in the past had an issue with alcohol abuse? “I drink socially, maybe once a week.”
– Do you currently smoke cigarettes or vape? “No.”
– Do you smoke marijuana? “No, not anymore.”

—

### Medical History
– Medical problems: Asthma
– Previous surgeries: Appendectomy at age 16

—

### Mental Status Exam

**Appearance and Behavior**
– **Appearance:** Well-groomed, dressed appropriately for the weather
– **Behaviors:** No abnormal movements, maintains good eye contact
– **Attitude:** Cooperative and open
– **Level of Consciousness:** Alert and oriented
– **Orientation:** Fully oriented to person, place, time, and situation
– **Rapport:** Established good rapport with the clinician

**Speech**
– **Quantity:** Talkative
– **Rate:** Normal
– **Volume:** Normal
– **Fluency and Rhythm:** Clear and fluent

**Affect and Mood**
– **Mood:** “I feel really low and anxious.”
– **Affect:** Sad, congruent with mood
– **Fluctuations:** Even
– **Range:** Restricted
– **Intensity:** Normal
– **Quality:** Sad, anxious
– **Congruency:** Congruent mood and affect

**Perception**
– **Paranoia:** Mild; feels people talk about her
– **Hallucinations:** None reported

**Thought Content**
– **Suicidal:** Yes, with a plan
– **Homicidal:** No
– **Delusions:** None
– **Ideas of Reference:** Mild; feels people talk about her

**Thought Form/Process**
– **Descriptors:** Linear, goal-directed

**Cognition**
– Cognitive testing appropriate for education level: No significant deficits noted

**Insight**
– **Understanding:** Good understanding of her condition
– **Reality-testing:** Adequate
– **Help-seeking:** Actively seeking help

**Judgment**
– **Actions:** Currently not engaging in harmful behaviors
– **Decision-making:** Reasonable, but impaired by mood disorder

—

### Medications

**Medical Medications:**
– Albuterol inhaler for asthma

**Psychiatric Medications:**
1. **Medication:** Fluoxetine (Prozac)
– **Dose at the time of visit:** 20 mg daily
– **Starting dose:** 10 mg daily
– **How does this medication work?** Increases serotonin levels in the brain to help improve mood.
– **Major side effects:** Nausea, headache, insomnia, sexual dysfunction.
– **Is this medication FDA approved for why the person is using this medication?** Yes, for depression and anxiety.
– **Patient education:** Discuss potential side effects, importance of adherence, and not stopping medication abruptly.
– **Medication class:** Selective Serotonin Reuptake Inhibitor (SSRI)

—

### Psychiatric Diagnosis
**Current Diagnosis:**
1. Major Depressive Disorder (MDD)
2. Generalized Anxiety Disorder (GAD)

**DSM-5 Symptom Criteria:**
1. **Major Depressive Disorder:**
– Depressed mood most of the day, nearly every day
– Markedly diminished interest or pleasure in all, or almost all, activities
– Significant weight loss or gain
– Insomnia or hypersomnia
– Psychomotor agitation or retardation
– Fatigue or loss of energy
– Feelings of worthlessness or excessive guilt
– Diminished ability to think or concentrate
– Recurrent thoughts of death or suicide

2. **Generalized Anxiety Disorder:**
– Excessive anxiety and worry occurring more days than not for at least 6 months
– Difficulty controlling the worry
– Associated with three or more of the following symptoms:
– Restlessness or feeling keyed up or on edge
– Being easily fatigued
– Difficulty concentrating or mind going blank
– Irritability
– Muscle tension
– Sleep disturbance

**Displayed/State Symptoms:**
– Meets criteria for both MDD and GAD based on the symptoms described and observed.

—

### Billing/Coding
**ICD 10 Code:**
– Major Depressive Disorder: F33.1
– Generalized Anxiety Disorder: F41.1

**Billing Code:**
– 99214: Established patient office visit, moderate complexity

—

### Treatment Plan
**Medication Changes Made During Visit:**
– Continue Fluoxetine 20 mg daily
– Consider augmenting with Buspirone for anxiety if no improvement in 4 weeks

**Clinical Impression:**
– Patient presents with symptoms of major depressive disorder and generalized anxiety disorder, requiring ongoing medication management and psychotherapy.

**Recommended Therapy/Support Sources:**
– Cognitive Behavioral Therapy (CBT) for both depression and anxiety
– Support groups for additional peer support
– Referral to a psychiatrist for possible medication adjustments

**Next Visit Scheduled:**
– Follow-up visit in 4 weeks to reassess symptoms and treatment efficacy

—

### Reflection on Domestic Violence Implications
If domestic violence were suspected, the plan of care would include:
– Ensuring the patient’s immediate safety
– Referring to appropriate resources such as shelters and hotlines
– Incorporating trauma-informed care strategies into the treatment plan
– Adjusting the care plan to include regular assessments for safety and well-being

References
– American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).
– National Institute of Mental Health. (2022). Depression. https://www.nimh.nih.gov/health/topics/depression/index.shtml
– National Institute of Mental Health. (2022

 

 

MRU PMHNP Clinical Write-Up

Student Name:

Write Up #

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?) · Delusions are fixed, false beliefs. · These are unshakable beliefs that are held despite evidence against it, and despite the fact that there is no logical support for it. · Is there a delusional belief system that supports the delusion?
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

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