Case Analysis Evaluation 3 Instructions
Chief complaint: “My employer said I need to come.”
HPI: Rachel is a 26 Years old black female who presents to the clinic seeking treatment per recommendation of the director at the day care center where she works. She says that she does not understand why she needs psychiatric treatment and feels that the director is being irrational. She describes her director in negative terms, making clear that she knows more about running a day care center than her director. Rachel states she’s committed to her job and has been through several positions because she’s not able to get along with others. She reports that she is easily angered and views authority figures with deep suspicion. She sees herself as flawed, broken, unloved, and unlovable. She reports suicide thoughts when feeling down, lost, hopeless, and alone. She states that the only thing that help her with these experience is to inflict pain on herself. Racheal was proud to show off the old scar of superficial cuts and burns. Denies sudden weight loss, excessive sweats, hair loss, and chronic fatigue.
Psychiatric History: Rachel has never been psychiatrically hospitalized and has never seen a psychiatric provider. She states that she did spoke to her minister and college chaplain while in college for emotional issues. States primary care provider had prescribed fluoxetine 20mg for some time but unsure as to whether this been of any benefit. Onset of symptoms- Anxiety- “all my life,” self-mutilation, chronic feelings of emptiness started at age 18, depression “on and off all my life,” anger started around age 18.
Past Medical History: Rachel is in good physical health with no medical hospitalizations.
Surgical History: None
Family Medical History: Mother- Anxiety, HTN; died at age 53. Father- CHF; died at age 66-years. Brother- Stomach ulcer, tobacco smoker. Sister has anxiety and depression
Social History: Rachel lives alone in a rental apartment. She buys a bottle of liquor after work on some days and goes home to drink until she passes out. She will wake up in the morning some days to find herself with someone she had pick up from the bar and whose name she’s unable to recall. When asked about safe sex practices, she refused to respond. Rachel states does not have much friends because she does not get along with people in general. Denies history of tobacco use. Denies legal history.
Educational/Occupational History: Rachel completed high school and did well at school. Complete two years of college. She works full time at the day care, unable to maintain a job over 1year. Previous jobs includes various fast food restaurants, departmental stores, customer service call center and day care centers.
Developmental/Family History– Rachel is the youngest of three children. She was born and raised on a rural area in a Southern state. She describes childhood as lonely and unhappy. She states that was why she moved to the city after high school. She denies developmental problems. She did not have good relationship with siblings and relatives. Older brother and sister are married and live in houses on parent’s property. Rachel describes her parents as hardworking. She says father had retired to work on his farm before he passed away. Her mother never worked outside the home and still works on the farm. Mother’s sister also lives on same property.
Review of Systems: 10-system ROS negative except symptoms noted in HPI.
Medications: Fluoxetine 20mg once a day
Allergies: NKDA
Vital Signs: BP 128/80 HR 62bpm, T 98.9F, RR 18/min Weight 150lbs without significant recent changes.
CAE 3 Instructions
Review the above case study and complete the CAE Sections below. Remember to use appropriate APA in-text citations and reference list.
A. Health History/History of Present Illness. Identify history questions to be obtained to discriminate critical characteristics of the presenting chief complaint (symptom).
B. Differential Diagnosis: Delineate 4 differential diagnosis that could support the chief complaint and HPI. Include DSM-5 diagnostic code for each of the differential diagnosis.
C. Mental Status Examination: Delineate mental status exam findings that would be associated with each listed differential diagnosis.
D. Etiology: Delineate the etiology of each of the 4 differential diagnosis. Include psychosocial factors and past experiences that may be contributing to current symptoms.
E. Diagnostic Screening Tools: Delineate what diagnostic screening tools would be appropriate for each of the 4 differential diagnosis.
F. Analysis: Delineate your final assessment along with rationale.
G. Treatment Plan: Delineate appropriate treatment plan which should include psychological therapeutic modalities and the focus, social interventions (support or self- help groups, mobilization of family resources, vocational rehabilitation, financial planning) and identification of strengths.
