You will be assigned a mental health disorder commonly seen in primary care and you will create a case study based on that disorder. You may create a case study either from a previous clinical patient experience or if you have not had a patient in clinical that represents your assigned topic you may research your disease using the week’s classroom material and the evidence-based literature in the field. The case should be clear and include all elements of a normal case that might be presented in class (subjective, objective, assessment, and full 5 point plan).  The clinical practicum documentation will be helpful for this process, or notes you have taken in clinical regarding cases.  The case should be clear, organized, and meet the following guidelines:

Week 6 Part One:

This part goes in part one and should begin with subjective and objective data just like we do in your weekly case study discussion.  Do not put diagnosis until your peers respond.

WEEK 6 Part One: The case should lead the class toward the mental health diagnosis assigned to you by your instructor.

WEEK 6 Part One Specific Guidelines:

If this is an actual patient from clinical- Include their actual chief complaint, demographic data, HPI, PMHX, PSHX, medications, allergies, subjective and objective findings without identifying the patient’s name.

If this is a fictitious case you’ve created from the literature/readings you should design an example patient and include chief complaint, demographic data, HPI, PMHX, PSHX, medications and allergies, subjective and objective findings. Be mindful that the background data for the case should bear some relevance to the diagnosis.

The case should not be overly simple. Like your weekly case studies, it should include subjective data that loosely represents the diagnosis you have been given, but includes some elements of the pathophysiology/presentation of the disease.

You must include the following elements in part one: subjective: chief complaint/HPI, demographic data, HPI, PMHX, PSHX, subjective and objective findings.


Leading the discussion in part one:  You must respond to any student who posts regarding your case with a substantial response, either answering their questions or noting their response and acting as leader. You also must respond to any faculty responses to your initial posting. Use references to support your responses. Remember: Your response to your peers is part of where you demonstrate your knowledge of the disease you were assigned. You should be discussing hallmark symptoms, diagnostic tools etc along with discussing the student’s impressions and conclusions.  Once your peers respond you can share the primary diagnosis and treatment plan that actually occurred if it is a live patient, and the ideal treatment plan if it is an invented case. Your treatment plan should address any national guidelines as appropriate for the diagnosis.

**It is important to use descriptive terms and avoid words such as: depressed, anxious, bipolar, (describing the presentation so, it is visual to those interpreting). As you develop your case do not give the diagnosis away, it is up to your peer to tease out three mental health diagnoses and compare/contrast as to which would be the primary diagnosis and why the others are not. Consider the cases we have given you in weeks two and three, the story with SOAP note information. This should be in SOAP note format, and the information below is to assist with helpful terms often used in mental health exams.

*Should be in this format*
So here is some helpful terms to include in your presentation:

CC: A few words of patients complaint (this is NOT paragraph): Can’t stop crying

HPI: Brief story of why patient is presenting. (MANDATORY) Pt is a 45 y.o. female with hx of HTN, that presents with complaint of crying, states she …….

OLDCART – not mandatory – may place if you want

PMH: Patients medical history – HTN

PSH: Patients surgical history – Appendectomy, cholecystectomy

SH/FH: Social hx/Family: Married, 3 children that are alive and well. Mother passed from CAD, Father alive. Works as a FT Nurse, smokes 20 PPY hx, non-drinker, denies drinking alcohol.

Allergies: NKDA

Medications: Lisinopril 10 mg, daily.

ROS: (Subjective) What they tell you:

Constitutional: Gained 20 lbs over last year. Recent ….

HEENT: Complains of frequent HA’s, PND

PULM: New non-productive cough, denies wheezing

CV: Hx of cardiac murmur and NSVT, denies CP or recent palpitations

GI/GU: Denies N/V/D/Constipation, blood in urine or stool

EXT: Denies pain, tingling or numbness in upper or lower extremities, denies edema

Psych: Remote hx of over-eating, stress eating

PE: (Objective)

VS: T: 98.6 HR: 65 RR: 18 BP: 110/68 HT/WT: 66"/220 BMI:X

Appearance: Wearing (clean/dirty X), shirt buttoned, unbuttoned, appears stated age

Attitude: un/cooperative

LOC: Alert/distracted/sleeping

HEENT: Tenderness over frontal sinus.Normocephalic, PERRLA, Neck midline, supple, no lymphadenopathy, no carotid bruit or thrill

PULM: Clear to all bases, A/P symmetrical

CV: RRR, S1 S2 no click, rub, gallop

GI/GU: Abdomen soft, non-tender, no masses, GU deferred

EXT: No clubbing, cyanosis or edema, palp DP/PT bilat 2+/2+


Orientation/consciousness: X4

Attention: ?sufficient for conversation

Memory: ?sufficient for conversation

Intellectual: Assessed?

Speech/thought: shouting, rapid, pressured, teared,

Affect/mood (observed): frustrated, angry, happy, amicable, labile

Thought processes: linear, goal directed,

Thought content: delusional about . . ., preoccupied
Reliability/Insight/Judgement: present, absent

Suicidial ideation/ Homicidial ideation (SI/HI)?

Make sure to include validated testing scores such as:
PHQ-9, GAD-7, (find the one that matches with your diagnosis!)
Mobility Inventory for Agoraphobia (MIA)

Do not give diagnosis
Do not need to include references until the end.
These are just a few examples…




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