1. Together with your partner, select a case study from the general instructions for the Case Study Partner Project.
2. One partner will play the patient, while the other partner interviews. If you need a refresher on intake skills, please refer to your textbooks from the assessment course.
3. Do not change any of the core information from the case, but you may add whatever details you need in order to complete the evaluation form.
Case study: Linda is a 53 year old female referred to you by her primary care provider. Her chief complaint is severe anxiety, and the PCP has been giving an as-needed benzodiazepine for approximately 2 years. The PCP is concerned that Linda has been taking the medication with increasing frequency and has requested that psychiatry manage this case. Linda presents in your office as fidgety and nervous, stating "you can't take my medication away. I can't live without it.
*Review of Systems
Review of Systems should include both positive and negatives to show that symptoms were reviewed. Example "endorses hopelessness and depression, denies crying spells, SI/HI, and worthlessness."
History
Medical, psychiatric, family psychiatric, and psychosocial history are complete, in-depth, graduate level work
PSYCHIATRIC AND MEDICAL REVIEW OF SYSTEMS
Mania:
Depression:
Anxiety/panic:
Obsessions/compulsions:
Trauma:
Psychosis:
Memory/Concentration:
Sleep:
Appetite:
Neuro:
Cardio:
Respiratory:
GI:
GU:
Pain:
CURRENT MEDICATIONS:
PSYCHIATRIC HISTORY:
Medications:
Hospitalizations:
Counseling/Therapy:
Suicide Attempts:
Substance Use:
MEDICAL HISTORY:
Illness/Injuries:
Surgeries:
Allergies:
Pregnancy/Contraception:
HABITS:
Alcohol:
Drugs:
Caffeine:
Tobacco:
Supplements:
FAMILY PSYCHIATRIC HISTORY:
PSYCHOSOCIAL HISTORY:
Developmental and Educational History:
Current Family:
Social Supports/Faith:
Adverse life events: