Mental Health Case Study

Introduction

In this mental health case study, you will simulate a patient visit. You will be asked a series of questions regarding the evaluation, diagnostic workup, and follow-up plan. You will listen to and assess the patient's risk of suicide and determine a treatment plan.

At the end of the scenario, you will enter your name and save a summary of your answers in an Adobe PDF document that you will submit in your course assignment.

Trey’s Office Visit

Trey is a 40-year-old male who presents to your clinic to discuss new onset of anxiety and depression.

Hi, Trey; it’s good to see you. Tell me what brings you in today.

Hi. I have just been feeling down lately and very anxious.

I am sorry to hear that you are feeling down and anxious. Can you tell me a little more about it?

Trey’s Office Visit Transcript

History of Present Illness (HPI)

What questions would you include in your HPI of Trey?

Type your answers in the following text box. When you have finished, select the Submit button.

HPI Questions You Should Ask Trey

How long has this been going on?
Did anything trigger it?
Does anything make it better?
Does anything make it worse?
What have you tried to help with the depression and anxiety?
Do you have a support system?
Do you feel like you want to hurt yourself?

Trey’s HPI

Watch the following video, which describes an interaction between the nurse practitioner and her patient Trey.

Trey's HPI Transcript

GAD Anxiety Questionnaire

Here is a copy of Trey’s answers on the questionnaire. Answer the question that follows.

Trey marks all categories at 1’s (several days). Total score is 7

How would you interpret Trey’s total score?

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A score of seven is consistent with mild anxiety.

PHQ-9 Questionnaire

After assessing Trey’s GAD Anxiety Questionnaire score, you tell him you have one more questionnaire for him. You tell him it’s a short questionnaire to gauge whether he might suffer from depression. Here is a copy of Trey’s answers on the PHQ-9 questionnaire. Answer the question that follows.

Trey scores a total score of 7 for the first 9 questions. For the final question, he selects the option for somewhat difficult

Trey scores a total of seven on the PHQ-9 Questionnaire. How would you interpret his results?

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Trey’s score is consistent with mild anxiety.

Treatment Recommendations

After assessing both scores and determining the diagnosis, you tell Trey his results show he has mild anxiety and depression.

What do you recommend to Trey for treatment? When would you recommend he follow up? Provide at least one evidence-based reference to support your answer.

Type your answers in the following text box. When you have finished, select the Submit button.

Trey’s Treatment Plan

You explain Trey’s treatment and follow-up plan to him.

Typically, mild anxiety and depression are treated with psychotherapy as well as medication. This is likely situational and will, hopefully, improve over time. With the right treatment, we can hope to get this under control and get you feeling better. How does that sound?

That sounds good. Thank you so much for your help.

Great. I would like to see you back in six weeks to see how you are doing. Please be sure to call me if you have any side effects from the medication or if any of your symptoms get worse.

I will. Thank you!

Trey’s Treatment Plan Transcript

Summary

You will now save the information you have selected and typed into a summary document. Type in your first and last name. Then, your results will display, with instructions on how to download and save your file as a PDF document.