# 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:**
– “I feel sad and hopeless most days. I have no energy and can’t enjoy anything.”
– Nothing really helps, maybe sleeping.
– Being alone and thinking too much makes it worse.
– It’s there almost all the time.
**Anxiety:**
– It comes and goes, but it’s getting worse.
– Stress makes it worse; sometimes deep breathing helps a bit.
– Yes, I go into panic maybe once a week. It lasts for about 10-15 minutes.
**Mood Swings:**
– Yes, sometimes I feel better, but then I feel terrible again.
– I can go from feeling okay to crying and feeling hopeless in a matter of hours.
**Anger/Irritability:**
– Yes, small things set me off.
– I shout and sometimes throw things.
**Attention and Focus:**
– Yes, I can’t focus on anything for long.
**Current Self-Harm, Suicidal/Homicidal Ideations:**
– Yes, I’ve thought about it.
– I’ve thought about overdosing on my medication.
**Hallucinations:**
– No, I don’t.
**Paranoia:**
– Sometimes I feel people are talking about me behind my back.
**Sleep:**
– Yes, it takes me hours to fall asleep.
– About 2-3 hours to fall asleep.
– I wake up several times a night.
—
## Past Psychiatric History
– Symptoms started in my early twenties.
– Diagnosed with major depressive disorder at 25.
– Parents divorced when I was 18.
– I’ve been on and off different antidepressants; they help a bit but never fully.
– Medications tried: 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
– I used marijuana in college, but not anymore.
– I drink socially, maybe once a week.
– No, I do not currently smoke cigarettes or vape.
– No, I do not smoke marijuana 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. **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). Anxiety Disorders. https://www.nimh.nih.gov/health/topics/anxiety-disorders/index.shtml
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