Part 1
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.

Sample Paper

Chief Complaints

The patient complains of episodes of intense fear, lightheaded and dizziness.

History of Present Illness

Pt is a 40-year-old female who presents with a chief complaint of recurrent episodes of intense fear, abdominal pain, nausea, lightheaded, unsteadiness, and feeling dizzy. She reports that the fear episodes and associated abdominal distress, nausea, and lightheaded began 2 weeks ago. The patient also reports unsteadiness and feeling dizzy, which began two months ago. When asked about the location of the abdominal pain, she reports experiencing lower abdominal distress. The patient reported the duration of the abdominal distress to be between one to two hours every day. According to the patient, the headaches are dull, occur rarely with pain levels of two out of ten. Some of the aggravating factors of the chief complaints included stress and caffeine intake. The patient reported that symptoms usually aggravate during the daytime. When asked about factors that relieve symptoms, Pt reported that taking loperamide helps to reduce the severity of abdominal distress. Loperamide frequency of administration is three times a day. The patient reports that the fear episodes are interfering with her ability to go to work and attend social functions, thus she decided to seek medical care.

Past Medical History

  • Asthma
  • Diabetes

Immunization: up to date

Surgeries: No major surgeries were reported

Social History

Occupation: Mid-American Copy & Ship supervisor

Hobbies: Watching documentaries, free talks at church, and reading

Denies changes in sleep or more significant drowsiness or yawning;

Denies acknowledging the role that drugs or alcohol played in the present illness, accepts that chief complaints are interfering with daily activities

Family History

  • Denies family history of panic disorder, migraine, and seizures
  • Mother: HTN and type 2 diabetes
  • Father: hypertension
  • Grandfather: hypertension and lung cancer

Sexual History: Pregnant. Not lactating. Sexually active. No contraceptives

Mental Diagnosis: Reports mental history of depression or anxiety

Violence History: Reports safety concerns

ALLERGIES: Positive history of asthma.

Medications: Two hundred milligrams of loperamide

Review of Systems

Constitutional: Positive for lightheadedness. Denies headaches


Head: positive for mild headaches

Eyes: Reports dullness.

Ears: Denies hearing loss

Nose: Denies runny nose

Throat: No sore throat.

SKIN: No itching or rash.

CARDIOVASCULAR: Denies chest pain and pressure.

RESPIRATORY: Denies cough and shortness of breath.

GASTROINTESTINAL: Reports vomiting, nausea, anorexia, or diarrhea as well as     abdominal pain.

GENITOURINARY: Denies increased urination

NEUROLOGICAL: Reports headache and dizziness.

MUSCULOSKELETAL: Negative for any musculoskeletal disorder.

HEMATOLOGIC: Negative for anemia.

LYMPHATICS: Denies history of splenectomy.

PSYCHIATRIC: Reports depression and anxiety history.

ENDOCRINOLOGIC: Denies polydipsia or polyuria

REPRODUCTIVE: Sexually active. Positive for pregnancy.

Objective Data

Physical Examination


Blood Pressure: 100/80

Pulse: 69,

T: 96.7 F,

H: 50′,

W: 130.

Appearance: Wears clean clothes

Attitude: Cooperative

LOC: Alert

HEENT: Reports dullness

PULMONARY: Wheezes are absent.

CARDIAC: Regular heart rate.

GI: Bowel sounds are active.

GU: Genitalia discharge absent

Extremities: No edema

Psychiatric: No splenectomy.

Orientation/consciousness: Alert

Attention: sufficient

Memory: Good for conversation

Intellectual: Good

Speech/thought: Frustrated

Affect/mood: Frustrated

Thought processes: Linear

Thought content: Preoccupied

Reliability: Present

Suicidial ideation/ Homicidal ideation: PDSS-20