In this assignment, you will review the Depression Interactive Case Study patient scenario and analyze the data to determine the health status of the patient.
Select the Patient Subjective Information tab. Within this tab, you will be able to watch a video to gain more insight regarding the patient as well as view important patient details.
For this assignment, you will
Your case study write up should include specific reference to relevant guidelines and other clinical information. The national guidelines should also be considered within treatment plans.
When you have completed viewing the patient information, download the Comprehensive Case Study Paper Template (Word) from the assignment page in Moodle. Use this document to complete the assignment and then submit it to the assignment drop box. Additionally, there is an Exemplar document for review to help guide your case study write up.
Cesarian section-second daughter
Dysmenorrhea X 3 months
Mrs. Lane is the youngest of six children born to biological parents who raised her in Korea. She completed her BS degree in education. Came to the U.S. as a young adult, age 21. Received a Green Card and then became a U.S. citizen years after. All of her family of origin live in Korea, and she visits every two to three years. Recently widowed, two years ago. No history of alcohol or drug use. Currently works as a middle school math teacher. She has two grown children, both daughters, and one grandson age 5. One daughter lives in Washington DC, and the other lives in town with her husband and son. They visit frequently and live only a few houses down from her.
Last immunizations: Flu vaccine, one year ago, recent Covid vaccine, plus additional boosters X2.
Visited family one year ago in Korea
Reports usual health as “fine, no issues.” Denies fever, chills, weight changes.
Denies cough, dyspnea, or wheezing.
Denies past hx of asthma, recurrent infections.
Denies chest pain, palpitations.
Denies coordination problems, numbness, tingling, weakness, tremors. Denies seizures and frequent headaches.
Not aware of memory problem. Denies h/o head injury.
Admits depressed mood, although she is “frustrated” that she is having worse anxiety again as well. Admits to some apathy and decreased motivation. Denies suicidal or homicidal ideations.
Admits insomnia, difficulty falling asleep, some middle-night awakening, and disruption of 24-hour sleep cycle. Does report “wanting to sleep much more” and “no energy in the morning.” Additionally reports waking up in sweats.
Admits loss of interest or pleasure in activities, and social isolation. Specifically, her favorite thing, Saturday cooking, is no longer a priority.
Denies feelings of helplessness, hostility, low self-esteem, guilt, or shame. Endorses some feelings of hopelessness in her condition not improving.
Denies increased energy but does occasionally feel fatigued.
Has noticed she has some difficulty concentrating, has stopped watching TV, and is very forgetful at times. “I leave my keys everywhere and misplace my phone all day. That’s not normal for me.”
Denies increased or decreased appetite.
Denies delusions, hallucinations, feelings of persecution, hearing sounds that seem to be voices, or preoccupation with religion.
Denies self-inflicted injuries; has no frequent thoughts of death, lack of desire to continue living, or suicidal tendency.
Denies homicidal thoughts.
Denies family problems, poor school/work performance, recent separation, job loss, and legal problems; not under stress other than worrying about increased anxiety and feeling overall worse.
| Ht | 63 inches |
|---|---|
| Wt | 180 lbs. |
| Waist circumference | 40 |
| T | 98.9 |
| P | 82 |
| R | 18 |
| BP | 144/86 |
| BMI | calculate at every visit |
Mrs. Lane is a 42-y/o Korean American female who articulates very clearly, is not unsteady, ambulates without difficulty, and is in no acute distress. General appearance same as stated age, normal level of personal hygiene; no inappropriate clothing, no bizarre personal appearance, not overly thin, no body odor; does show as overweight on BMI chart.
Remainder of physical exam deferred during psychiatric mental health assessment.
A&Ox4, disheveled appearance. No spontaneous speech, but answers questions when asked.
No noted hypervigilance, heightened startle reflex, abnormal mannerisms, or uncommunicative/disinterested/hostile/inattentive attitude.
No tremor or tics; normal gait and stance; no involuntary movements.
No refusal to speak or loosening of association/word salad; not slowed, rapid, or difficult; normal rhythm of speech, speech tone, and speech volume.
Appears depressed; does not appear anxious, dysphoric, euphoric, elevated, expansive, irritable, or angry.
Full ranging, not blunted, constricted, flat, incongruent with mood, inappropriate, labile, sad, or tearful.
No language abnormalities; speech fluent; no dysphonia; no stuttering; language fluent and intact for naming; normal sentence structure.
Patient oriented x4; no disorientation, short-term memory impairment, reduced abstraction ability, or diminished cognitive functioning. Some delay in retrieving thoughts.
No deficiency on evaluation of connectedness; organized.
No thought content impairment; no suicidal ideation, homicidal ideations, paranoid ideations, poverty of thought, thought insertions, obsessions, irrational fears, delusions, or hallucinations.
No impaired insight, impaired judgment, or poor problem solving.
***No recent labs on file.