adequate references

Case Study: Petunia Park

Program Transcript

[MUSIC PLAYING]

DR. MOORE: Hi. Good afternoon. My name is Dr. Moore. Am I understanding you’re

here for a mental health assessment today?

PETUNIA PARK: That’s right.

DR. MOORE: OK. So to make sure I have the right patient and the right chart, can you

tell me your name and your date of birth?

PETUNIA PARK: Yes. I’m Petunia Park. My birthday is July 1, 1995.

DR. MOORE: And can you tell me what today’s date is?

PETUNIA PARK: So it’s December 1.

DR. MOORE: Do you know the year?

PETUNIA PARK: 2020.

DR. MOORE: And what day of the week is this?

PETUNIA PARK: It’s Tuesday.

[CHUCKLING]

DR. MOORE: And do you know where we are today?

PETUNIA PARK: Yes I am here in the beautiful, sunny office at the clinic.

DR. MOORE: OK, great. Thank you. So can you tell me a little bit about why you’re here

today? What brings you here today?

PETUNIA PARK: Yes. So I have a history of taking medications and then stopping

them. I don’t think I need them. I really feel like the medication squashes who I am.

DR. MOORE: OK, OK. So I’m going to be able to help you with that. But to begin, I’m

going to ask you some questions about your family. I’m going to ask you some historytype questions. I’m going to ask you some symptoms that you might be having. And all

of these questions are going to help me work with you on a treatment plan, OK? So I

would like to begin with, when was the first time that you ever had any mental health or

substance use treatment in your life?

Case Study: Petunia Park

PETUNIA PARK: OK.

Well, when I was a teenager, my mom put me in the hospital after

I went four or five days without sleeping. I think I may have been hearing things at that

time.

[CHUCKLES]

I think they started me on some medication, but I’m not sure.

DR. MOORE: Oh, OK so you were hospitalized. How many times have you been

hospitalized for mental health?

PETUNIA PARK: Oh, I’ve been hospitalized about four times. The last time was this

past spring. No detox or residential rehabs, though.

DR. MOORE: OK, good. Were any of these hospitalizations due to any suicide

gestures?

PETUNIA PARK: One was in 2017. I overdosed on Benadryl, but I’ve not had those

thoughts since then.

DR. MOORE: Well, I’m very glad to hear that you’ve not had any of those thoughts

since then. And I’m glad that you turned out OK from that overdose. I’m glad that you’re

here today. Can you tell me a little bit about what you’ve been diagnosed with during

your past treatments?

PETUNIA PARK: Well, I think depression, and anxiety, had some even say maybe

bipolar.

DR. MOORE: OK, and what medications have you been tried on before for those

illnesses? And if you can remember, what was your reactions to those medications?

PETUNIA PARK: Oh, let’s see. Oh, I took Zoloft, and that made me feel really high.

[CHUCKLES] I couldn’t sleep. My mind was racing, and then I took risperidone. That

made me gain a bunch of weight. Seroquel gave me weight, too. I took Klonopin, and

that seems to slow me down some.

I really can’t remember the others. I think the one I just stopped taking was helping. It

started with an L, I think. I don’t really remember the name, but it squashed me in

creativity.

DR. MOORE: OK, well, we’re going to try to help you find some medication that doesn’t

make you feel squashed or have any of those negative side effects today. But in order

to do that, I need some more information. And the next questions I’m going to ask you

are about substances you may have used. And I want you to know that you don’t get in

trouble in here if you’ve used some of these substances. It really just helps me to make

sure that what’s in your system that could be impacting your neurochemistry. And when

we do talk about medications, so I don’t give you something that would negatively

interact with something you may be using, OK? So do you–

PETUNIA PARK: OK.

DR. MOORE: –use any nicotine?

PETUNIA PARK: Yes. I smoke about a pack a day, and I’m not going to quit for you,

either. [CHUCKLES] Oh.

DR. MOORE: That’s OK, that’s OK. And what about alcohol? When was your last drink

of alcohol?

PETUNIA PARK: When I was 19 because alcohol and me do not work well together.

[CHUCKLES]

DR. MOORE: OK, and what about any

marijuana?

When was your last use of any

marijuana?

PETUNIA PARK: Oh no. I tried that once and got really paranoid.

DR. MOORE: OK. What about any last use of cocaine?

PETUNIA PARK: Never.

DR. MOORE: Last use of any stimulants or methamphetamines?

PETUNIA PARK: Never.

DR. MOORE: What about any huffing or inhalants?

PETUNIA PARK: Never.

DR. MOORE: OK, have you used anything like Klonopin or Xanax, any of those

sedative medications?

PETUNIA PARK: Never.

DR. MOORE: All right, good. What about any hallucinogenics like LSD, or PCP, or

mushrooms?

PETUNIA PARK: No, never.

DR. MOORE: Wonderful. OK, what about any use of pain pills or opiate medications?

Anything prescribed or anything you’ve obtained from the street?

PETUNIA PARK: No, never.

DR. MOORE: Good. And anything synthetic like Spice, or ecstasy, Bath Salts, Mollies,

anything like that?

Case Study: Petunia Park
PETUNIA PARK: Never.

DR. MOORE: Oh, wonderful. Well, I’m glad to hear that. You know those things aren’t

good for your brain. So I encourage you to continue to stay away from those things.

Have you ever had any blackouts or seizures from drugs or alcohol? Or seen things that

you weren’t sure were there?

PETUNIA PARK: Never.

DR. MOORE: Good. What about any legal issues or any DUIs?

PETUNIA PARK: Never.

DR. MOORE: OK. Good, good. All right, so I’m just going to ask a little bit about your

family right now. Any blood relatives have any mental health or substance abuse

issues?

PETUNIA PARK: Yeah, well, well, why would you ask that? It’s not your business.

DR. MOORE: Right. I could see where you might find that wouldn’t be any my business.

But really, sometimes these issues can be genetic. They’re alarm behaviors. So my

understanding of your family helps me to understand you.

PETUNIA PARK: Huh. Well, my mother was seen as crazy. I think they said she had

bipolar or something. And my father went to prison for drugs. And well, we haven’t

heard, or seen, or heard from him in 8 or 10 years. My brother, while I think he’s a little

schizo, but he hasn’t ever went to the doctor. Nobody else with anything.

DR. MOORE: OK. So that sounds like it must be tough growing up not seeing your

father and having some of those issues in your family. But any family, blood relatives

commit suicide?

PETUNIA PARK: Well, my mom tried, but nobody really did it, you know?

DR. MOORE: OK. Have you ever done anything like that, or anything like cut on

yourself, burn yourself?

PETUNIA PARK: I already told you, I tried to kill myself. Why ask me that again? No, I’m

not going to kill myself or anyone else, and I don’t cut myself.

DR. MOORE: OK. Well, I’m glad to hear that. And I want you to know that I am here for

you, and we most certainly will make sure you have a crisis like number at the end of

this session if you do have those thoughts in the future. So I’m glad to hear that you

don’t have those thoughts today. OK. What type of medical issues do you have?

PETUNIA PARK: Oh, hoo. Let’s see. I have a thyroid issue that I take some medicine

for, that hypothyroidism. And I take a birth control pill for polycystic ovaries.

DR. MOORE: OK, when was your last menses?

PETUNIA PARK: Oh, well I have a regular one each month. So let’s see. It was last

month sometime.

DR. MOORE: OK, so any chance that you’re pregnant?

PETUNIA PARK: [LAUGHS] Lordy, no. I may have a lot of sex around, but I’m safe.

DR. MOORE: Hm. You “have a lot of sex around.” Can you maybe tell me what that

means?

PETUNIA PARK: Well, it’s exciting and thrilling to find new people to explore sex with. It

helps me keep my moods high, high, high. [CHUCKLES]

DR. MOORE: OK, so that makes you feel really high and kind of what, OK?

PETUNIA PARK: Oh yeah.

DR. MOORE: So who raised you?

PETUNIA PARK: My mom and my older brother, mainly.

DR. MOORE: And who do you live with now?

PETUNIA PARK: Well, I live with my boyfriend. And sometimes, stay with my mom

when he gets mad at me for sleeping around some.

DR. MOORE: So that’s created some issues in your relationship, I see. OK. Are you

single, married, widowed, or divorced?

PETUNIA PARK: I’ve never been married.

DR. MOORE: OK. Do you have any children?

PETUNIA PARK: No.

DR. MOORE: All right. Are you working?

PETUNIA PARK: Yes, I work part time at my aunt’s bookstore. She’s more tolerant of

the days I don’t come in from feeling too depressed.

DR. MOORE: OK, so I hear some, maybe, feelings of depressed. OK. What is your

level of education?

PETUNIA PARK: Oh, I’m in vo-tech school right now for cosmetology. I’m going to do

makeup for movie stars. [CHUCKLES]

DR. MOORE: Oh, that sounds really wonderful. OK, so but what about now? What do

you do for fun now?

PETUNIA PARK: Well, I am writing my life story, and it’s going to be published. I also

paint like Picasso. I’m going to sell those paintings to movie stars, too.

DR. MOORE: Well, that’s wonderful. Maybe someday you can show me your paintings

as well. OK, have you ever been arrested or convicted for anything?

PETUNIA PARK: No. The police did pick me up and take me to the hospital once. I

didn’t have much sleep that week. And they said I was dancing around in my nightgown

in a field with my guitar. I really don’t remember much of that, though. I think maybe my

mom made up that story against me because she wanted me to go back to my

boyfriend’s house.

DR. MOORE: OK, so that was one of your hospitalizations that we talked about earlier.

OK, what about any history of trauma with childhood or adult? Any kind of physical,

sexual, emotional abuse?

PETUNIA PARK: Well, my dad was pretty hard on us when he was around. But he

didn’t really touch us or anything. More just yelled at us a lot.

DR. MOORE: OK. All right, so I’ve gathered some history here. Now, I want to get into

more of some of the symptoms that brought you in to see me today. So you mentioned

before that sometimes your depression keeps you from working at your aunt’s

bookstore. Can you tell me a little bit more about what that looks like for you?

PETUNIA PARK: Well, about four or five times a year, I have these times when I just

don’t want to get out of bed. I have no energy, no motivation to do anything. I just can’t

feel any interest in my creativity. I feel like I’m not worth anything because I feel that

creativity slipping away.

So this is usually happening after I’ve been up for five days working hard on my works

with my writing, painting, and music. Everyone says I’m depressed, but I’m not sure. It

could be that I’m just exhausted from working so hard.

DR. MOORE: OK, so I hear you talking about these creativity episodes right before you

crash. Per se, this depression. Tell me a little bit more about those episodes. What do

those look like for you?

PETUNIA PARK: Oh, I love those times. Those are the reasons I don’t always take my

medication because I feel like I’m squashed. I have lots of energy to do a lot of things.

Base on the media, develop a focused SOAP Note, including differential diagnosis and critical-thinking process to formulate a primary diagnosis.

Additional information for the case presentation: The patient presents with bright vibrant colored clothing and heavy makeup. She had disheveled long hair, was unkept.

Temp 98.2 Pulse 90 Respiration 18 B/P 138/88

Laboratory Data Available: Urine drug and alcohol screen negative. CBC within normal ranges, CMP within normal ranges. Lipid panel within normal ranges. Prolactin Level 8; TSH 6.3 (H)

Incorporate the following into your responses in the template:

1. Subjective: What details did the patient provide regarding their chief complaint and symptomatology to derive your differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life? 

2. Objective: What observations did you make during the psychiatric assessment?  

3. Assessment: Discuss the patient’s mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses with supporting evidence, listed in order from highest to lowest priority. Compare the DSM-5 diagnostic criteria for each differential diagnosis and explain what DSM-5 criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.

4. Plan: What is your plan for psychotherapy? What is your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters as well as a rationale for this treatment and management plan. Also incorporate one health promotion activity and one patient education strategy.

5. Reflection notes: What would you do differently with this client if you could conduct the session again? Discuss what your next intervention would be if you were able to follow up with this patient. Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), health promotion, and disease prevention that takes into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).

6. provides at least three current, evidence-based resources from the literature to support the assessment and diagnosis of the patient in the assigned case study. The resources reflect the latest clinical guidelines and provide strong justification for decision making.

Subjective:

CC(chief complaint):

HPI:

Substance Current Use:

Medical History:

· Current Medications:

· Allergies:

· Reproductive Hx:

ROS:

· GENERAL:

· HEENT:

· SKIN:

· CARDIOVASCULAR:

· RESPIRATORY:

· GASTROINTESTINAL:

· GENITOURINARY:

· NEUROLOGICAL:

· MUSCULOSKELETAL:

· HEMATOLOGIC:

· LYMPHATICS:

· ENDOCRINOLOGIC:

Objective:

Diagnostic results:

Assessment:

Mental Status Examination:

Diagnostic Impression:

Reflections:

Case Formulation and Treatment Plan: