Case Study-Summary Case Notes

Case Study-Summary Case Notes

Encounter One

A 37-year-old male is brought to the outpatient clinic complaining of gradual cognitive decline. The problem started three years ago. Working as an industrial researcher, he started making calculation mistakes that led to him losing his job. He has frequent bouts of forgetfulness, memory impairments, apraxia, and apathy. He was diagnosed with early-onset Alzheimers and was scheduled to begin treatment in the coming week.

Encounter Two

A 22-year-old female was referred to the psychiatric clinic for treatment of severe depression and anxiety. At the time of her referral, she couldn’t attend her college classes, had strong suicidal ideation and thoughts, and had been hospitalized twice in the past year for depressive symptoms. She was currently on fluoxetine but had not been compliant with her medications. The patient was diagnosed with severe depression and was advised to continue fluoxetine 20mg every day.

Encounter Three

A 65-year-old male was brought to the clinic accompanied by his wife with complaints of irritability, agitation, nightmares, and severe anxiety. The wife noted that these manifestations have been on and off for over 20 years but have intensified over the past two months. The patient is a war veteran, having been deployed in Afghanistan. He was diagnosed with PTSD and was scheduled to begin CBT.

Encounter Four

A 67-year-old female was brought to the clinic accompanied by her husband with complaints of social isolation, agitation, delusion, and amnesia. The husband noted that she is often detached from herself and is delusional. She was diagnosed with schizophrenia and started on risperidone 2mg every 24 hours. She was advised to visit the clinic after two weeks.

Encounter Five

A 20-year-old male reported to the clinic with complaints of feeling depressed and experiencing significant stress about school. He spends most of his time playing video games and has a hard time identifying what is enjoyable and what is not. He was diagnosed with social anxiety disorder. He was scheduled to begin cognitive behavioral therapy.

Encounter Six

A 70-year-old male was brought to the clinic with complaints of losing interest in most things he used to be interested in. He is also isolated and experiences insomnia. These symptoms began after the death of his wife. He was diagnosed with depression and started on fluoxetine 20 mg every 24 hours. He was advised to visit the clinic after two weeks.

Encounter Seven

An 81-year-old female presented to the clinic accompanied by her son for her routine clinical visitations for the management of schizophrenia. Her son reports that she has recently been experiencing intense hallucinations and is often not in touch with reality. She is currently on aripiprazole 15 mg every 24 hours. She was found to be schizophrenic and unresponsive to aripiprazole. She was switched to risperidone 2mg every 24 hours and advised to visit the clinic after five days.

Encounter Eight

A 71-year-old male presented to the clinic with symptoms of restlessness, excessive worry, and palpitations. He reported that the symptoms began over one month ago and had since been intensifying. He is a known diabetic. He was diagnosed with general anxiety disorder and started on duloxetine 120 mg every 24 hours. He was advised to revisit the clinic after one week.

Encounter Nine

A 12-year-old female was brought to the clinic accompanied by her mother. She had complaints of recurring bouts of sudden and intense anxiety. These episodes appear randomly with no identifiable cause. She was diagnosed with panic disorder and was scheduled to begin cognitive behavioral therapy. She was started on escitalopram 10 mg every 24 hours.

Encounter Ten

A 25-year-old female presented to the clinic accompanied by her mother. She had complaints of loss of interest, hopelessness, and social isolation. Her mother reports that she sometimes experiences intense mood swings and is easily agitated. She was diagnosed with bipolar disorder and started on sodium valproate 200mg every 12 hours and advised to visit the clinic after two weeks.

Encounter Eleven

A 31-year-old male was referred to the clinic after a failed attempted suicide. He has been experiencing suicidal thoughts and ideations for the past two months. Notably, this started after he lost his job. He also reports complaints of hopelessness. He was diagnosed with major depressive disorder and was scheduled for psychotherapy.

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A minimum of 80 patient encounters are required. ALL patient age populations must be seen across the lifespan (children, adolescents, adults, and older adults) Of those minimum 80 encounters, at least 5 patient encounters must be with age populations of children and adolescents (any combination to total at least a minimum of 5) and at least 5 patient encounters must be with age populations of adults and older adults (any combination to total at least a minimum of 5).

• Types of Patients: Patients receiving care for psychiatric, and substance use disorders across the life span to include children, adolescents, adults, and older adults. *
• Types of Services: Assessment and diagnosis of children, adolescents, adults, and older adults with acute and chronic psychiatric and substance use disorders.
• Possible Site Choices: Private practice, community psychiatric and/or counseling center, crisis centers, drug/alcohol rehabilitation center, college counseling center, employee assistance program (EAP) sites, or assisted living/Alzheimer’s facility, hospital or specialty care facility, jails/prison, or any other site where psychiatric assessment and diagnosing takes place (to be determined on an individual basis).

Assignment:

• Student Notes- Students must include a brief summary/synopsis of the patient visit—this does not need to be a SOAP note; however, the note needs to be sufficient to remember your patient encounter. Each note needs to be more than 50 words.

For example, I need 80 summary case notes to submit for my curriculum base on psychiatric care.

Note should look like:

A 53-year-old female is accompanied by her husband with a complaint of attempting suicide, fear of sleeping, guilt, and confusion. The husband reports that the Patient was four years ago diagnosed with depression after the death of her son. She was diagnosed with depressive disorder and started on Citalopram 25mg daily. Pt is advised to come back for a review after four weeks.