Medical Scribe Training Course → Mock Patient #41: PSYCH EVAL – AGE 26 - Scribes4hire

Array
(
    [_lp_cert_thumbnail] => Array
        (
            [0] => 
        )

    [_vc_post_settings] => Array
        (
            [0] => a:1:{s:10:"vc_grid_id";a:0:{}}
        )

    [repeatable_fields] => Array
        (
            [0] => a:17:{i:0;a:3:{s:8:"question";s:15:"Chief Complaint";s:6:"answer";s:16:"Psych Evaluation";s:13:"preload_value";s:0:"";}i:1;a:3:{s:8:"question";s:26:"History of Present Illness";s:6:"answer";s:856:"The patient is a 26-year-old male with no significant past medical history who presents to the emergency department for a psych evaluation. He states that he has been feeling “low” for one month.  Symptoms began when the patient lost his job for an unknown reason. Since then, he has been sleeping for long periods of time and has not had the energy to do “things that he needs to do.” The patient also reports an increase in alcohol use since he became unemployed. He drinks around 8 beers and additional vodka daily. The patient’s last drink was last night. He has never been evaluated for depression prior to this episode. The patient denies recent drug use, suicidal ideation, homicidal ideation, self-harm, hallucinations, chest pain, abdominal pain, bowel or bladder concerns, or any other symptoms. No other reported symptoms at this time.";s:13:"preload_value";s:0:"";}i:2;a:3:{s:8:"question";s:17:"Review of Systems";s:6:"answer";s:89:"All pertinent positive findings are listed in the HPI and all other systems are negative.";s:13:"preload_value";s:0:"";}i:3;a:3:{s:8:"question";s:20:"Past Medical History";s:6:"answer";s:18:"Previously Healthy";s:13:"preload_value";s:0:"";}i:4;a:3:{s:8:"question";s:19:"Current Medications";s:6:"answer";s:4:"None";s:13:"preload_value";s:0:"";}i:5;a:3:{s:8:"question";s:9:"Allergies";s:6:"answer";s:23:"No known drug allergies";s:13:"preload_value";s:0:"";}i:6;a:3:{s:8:"question";s:14:"Social History";s:6:"answer";s:141:"Smoking Status - 1 pack per day
Smokeless Tobacco - No
Alcohol Use - 8 beers and vodka per day
Drug Use - No 
Sexual Activity - Not Asked";s:13:"preload_value";s:0:"";}i:7;a:3:{s:8:"question";s:14:"Family History";s:6:"answer";s:11:"MI - Father";s:13:"preload_value";s:0:"";}i:8;a:3:{s:8:"question";s:19:"Initial Vital Signs";s:6:"answer";s:3:"N/A";s:13:"preload_value";s:3:"N/A";}i:9;a:3:{s:8:"question";s:13:"Physical Exam";s:6:"answer";s:2107:"GENERAL: Alert and oriented x3. No significant distress noted.
HEENT: Normocephalic, atraumatic.  Pupils are 3mm equal round and reactive to light.  Nares are patent, without epistaxis.  There is no rhinorrhea.  Pharynx is moist and without erythema, exudate, or edema.  Uvula is midline.  Tympanic membranes are clear bilaterally.  There is no hemotympanum.
NECK: Supple, trachea is midline.  There is no JVD or carotid bruits.  There is no stridor.  There is no midline or paraspinal tenderness to palpation. There is no lymphadenopathy.
BACK: There is no midline or paraspinal tenderness to palpation, no evidence of trauma, there is no CVA tenderness.
CHEST: Symmetric, there is no crepitus. There is no visible evidence of trauma to the chest. 
LUNGS: Breath sounds are present and equal bilaterally, there are no rales, rhonchi or wheezes. There is no respiratory distress.
CARDIOVASCULAR: Regular rate and rhythm without murmur, rubs, clicks, or gallops. Normal S1 and S2.
ABDOMEN: Abdomen is nondistended. There is no palpable tenderness. There is no rebound or guarding. There is no palpable mass. Bowel sounds are present and equal throughout.
PELVIS: Stable to rock. There is no visible trauma.
MUSCULOSKELETAL: There are no deformities to the extremities. Capillary refill is less than two seconds to nail beds of the bilateral hands. There is no clubbing, cyanosis or edema. Radial pulses are +2/4 bilaterally.
NEUROLOGIC: The patient is alert and oriented x3. No cranial nerve deficit. Motor examination reveals +5/5 strength throughout. Sensation is normal throughout. Finger-to-nose intact. Heel-to-shin intact. Negative Romberg sign. Gait and station appear normal. Visual fields are full to confrontation.
SKIN: Skin is warm and dry. There is no pallor. There are no signs of acute dermatologic abnormality. There is no rash, petechiae, purpura, or ecchymosis. There is good skin turgor.
PSYCH: The patient does not have suicidal ideation or homicidal ideation.  Mood is depressed. The patient does not have auditory or visual hallucinations. Judgment and cognition are normal.";s:13:"preload_value";s:1928:"GENERAL: Alert and oriented x3. No significant distress noted.
HEENT: Normocephalic, atraumatic.  Pupils are 3mm equal round and reactive to light.  Nares are patent, without epistaxis.  There is no rhinorrhea.  Pharynx is moist and without erythema, exudate, or edema.  Uvula is midline.  Tympanic membranes are clear bilaterally.  There is no hemotympanum.
NECK: Supple, trachea is midline.  There is no JVD or carotid bruits.  There is no stridor.  There is no midline or paraspinal tenderness to palpation. There is no lymphadenopathy.
BACK: There is no midline or paraspinal tenderness to palpation, no evidence of trauma, there is no CVA tenderness.
CHEST: Symmetric, there is no crepitus. There is no visible evidence of trauma to the chest. 
LUNGS: Breath sounds are present and equal bilaterally, there are no rales, rhonchi or wheezes. There is no respiratory distress.
CARDIOVASCULAR: Regular rate and rhythm without murmur, rubs, clicks, or gallops. Normal S1 and S2.
ABDOMEN: Abdomen is nondistended. There is no palpable tenderness. There is no rebound or guarding. There is no palpable mass. Bowel sounds are present and equal throughout.
PELVIS: Stable to rock. There is no visible trauma.
MUSCULOSKELETAL: There are no deformities to the extremities. Capillary refill is less than two seconds to nail beds of the bilateral hands. There is no clubbing, cyanosis or edema. Radial pulses are +2/4 bilaterally.
NEUROLOGIC: The patient is alert and oriented x3. No cranial nerve deficit. Motor examination reveals +5/5 strength throughout. Sensation is normal throughout. Finger-to-nose intact. Heel-to-shin intact. Negative Romberg sign. Gait and station appear normal. Visual fields are full to confrontation.
SKIN: Skin is warm and dry. There is no pallor. There are no signs of acute dermatologic abnormality. There is no rash, petechiae, purpura, or ecchymosis. There is good skin turgor.
PSYCH: ***";}i:10;a:3:{s:8:"question";s:18:"ED COURSE:
Orders";s:6:"answer";s:4:"Labs";s:13:"preload_value";s:0:"";}i:11;a:3:{s:8:"question";s:11:"Lab Results";s:6:"answer";s:7:"Opioids";s:13:"preload_value";s:0:"";}i:12;a:3:{s:8:"question";s:10:"Procedures";s:6:"answer";s:4:"None";s:13:"preload_value";s:4:"None";}i:13;a:3:{s:8:"question";s:23:"Calls/Consults/Rechecks";s:6:"answer";s:344:"***: Discussed the patient’s case with Dr. Wallis (Psych). He will admit the patient. 

***: Rechecked patient who is resting comfortably. Lab results were discussed. The patient admits to using his roommate’s pain pills. The plan for admission under the care of Dr. Wallis (Psych). Patient agrees with plan. All questions were addressed.";s:13:"preload_value";s:0:"";}i:14;a:3:{s:8:"question";s:23:"Medical Decision Making";s:6:"answer";s:469:"The patient is a male who presents to the emergency department for a psych evaluation. Medical records were reviewed. Lab work was ordered and reviewed. Findings stated above. The patient was admitted under the care of Dr. Wallis (Psych) with a diagnosis of depression. The patient's vital signs and condition remained stable while undergoing evaluation in the Emergency Department. The patient agreed with the plan for care.  All questions and concerns were addressed.";s:13:"preload_value";s:676:"The patient is a @AGE@ @SEX@ who presents to the emergency department with a chief complaint of ***.  Medical records were reviewed. Multiple diagnoses were considered.  Lab work was ordered and reviewed. A *** was also ordered and reviewed. Imaging shows ***.  The patient was provided with *** resulting in *** of symptoms. The patient was diagnosed with ***. The patient was advised to ***. It was recommended for the patient to follow up with ***.  The patient was prescribed ***.  The patient's vital signs and condition *** while undergoing evaluation in the Emergency Department. The patient*** agreed with the plan for care.  All questions and concerns were addressed.";}i:15;a:3:{s:8:"question";s:16:"Final Impression";s:6:"answer";s:10:"Depression";s:13:"preload_value";s:0:"";}i:16;a:3:{s:8:"question";s:4:"Plan";s:6:"answer";s:133:"The patient is admitted under the care of Dr. Wallis (Psych) in stable condition and does not have any further questions or concerns.";s:13:"preload_value";s:0:"";}}
        )

    [lession_timer_num] => Array
        (
            [0] => 00:10:00
        )

    [patient_video] => Array
        (
            [0] => https://youtu.be/NwDfzgFHniY
        )

    [patient_video_title] => Array
        (
            [0] => Mock Patient #41: PSYCH EVAL - AGE 26
        )

    [disply_hpi] => Array
        (
            [0] => yes
        )

    [mock_video] => Array
        (
            [0] => 
        )

    [instrucors_video] => Array
        (
            [0] => https://youtu.be/ajd32Rlc93Y
        )

    [instrucors_video_title] => Array
        (
            [0] => Mock Patient #41 REVIEW: PSYCH EVAL - AGE 26
        )

    [scribe_example_pdf] => Array
        (
            [0] => 
        )

    [scribe_example_img] => Array
        (
            [0] => https://scribes4hire.com/wp-content/uploads/2018/04/Scribes4Hire.com-HPI-Sample.png
        )

    [slide_template] => Array
        (
            [0] => default
        )

    [_lp_duration] => Array
        (
            [0] => 10 minute
        )

    [_lp_preview] => Array
        (
            [0] => no
        )

    [_wc_memberships_force_public] => Array
        (
            [0] => no
        )

    [_wc_memberships_use_custom_content_restricted_message] => Array
        (
            [0] => no
        )

    [_lmt_disableupdate] => Array
        (
            [0] => no
        )

    [wp_last_modified_info] => Array
        (
            [0] => May 4, 2019 @ 9:51 pm
        )

    [wplmi_shortcode] => Array
        (
            [0] => [lmt-post-modified-info]
        )

    [_edit_lock] => Array
        (
            [0] => 1583125255:8
        )

    [_edit_last] => Array
        (
            [0] => 8
        )

    [count_items] => Array
        (
            [0] => 0
        )

)
Array
(
    [0] => Array
        (
            [question] => Chief Complaint
            [answer] => Psych Evaluation
            [preload_value] => 
        )

    [1] => Array
        (
            [question] => History of Present Illness
            [answer] => The patient is a 26-year-old male with no significant past medical history who presents to the emergency department for a psych evaluation. He states that he has been feeling “low” for one month.  Symptoms began when the patient lost his job for an unknown reason. Since then, he has been sleeping for long periods of time and has not had the energy to do “things that he needs to do.” The patient also reports an increase in alcohol use since he became unemployed. He drinks around 8 beers and additional vodka daily. The patient’s last drink was last night. He has never been evaluated for depression prior to this episode. The patient denies recent drug use, suicidal ideation, homicidal ideation, self-harm, hallucinations, chest pain, abdominal pain, bowel or bladder concerns, or any other symptoms. No other reported symptoms at this time.
            [preload_value] => 
        )

    [2] => Array
        (
            [question] => Review of Systems
            [answer] => All pertinent positive findings are listed in the HPI and all other systems are negative.
            [preload_value] => 
        )

    [3] => Array
        (
            [question] => Past Medical History
            [answer] => Previously Healthy
            [preload_value] => 
        )

    [4] => Array
        (
            [question] => Current Medications
            [answer] => None
            [preload_value] => 
        )

    [5] => Array
        (
            [question] => Allergies
            [answer] => No known drug allergies
            [preload_value] => 
        )

    [6] => Array
        (
            [question] => Social History
            [answer] => Smoking Status - 1 pack per day
Smokeless Tobacco - No
Alcohol Use - 8 beers and vodka per day
Drug Use - No 
Sexual Activity - Not Asked
            [preload_value] => 
        )

    [7] => Array
        (
            [question] => Family History
            [answer] => MI - Father
            [preload_value] => 
        )

    [8] => Array
        (
            [question] => Initial Vital Signs
            [answer] => N/A
            [preload_value] => N/A
        )

    [9] => Array
        (
            [question] => Physical Exam
            [answer] => GENERAL: Alert and oriented x3. No significant distress noted.
HEENT: Normocephalic, atraumatic.  Pupils are 3mm equal round and reactive to light.  Nares are patent, without epistaxis.  There is no rhinorrhea.  Pharynx is moist and without erythema, exudate, or edema.  Uvula is midline.  Tympanic membranes are clear bilaterally.  There is no hemotympanum.
NECK: Supple, trachea is midline.  There is no JVD or carotid bruits.  There is no stridor.  There is no midline or paraspinal tenderness to palpation. There is no lymphadenopathy.
BACK: There is no midline or paraspinal tenderness to palpation, no evidence of trauma, there is no CVA tenderness.
CHEST: Symmetric, there is no crepitus. There is no visible evidence of trauma to the chest. 
LUNGS: Breath sounds are present and equal bilaterally, there are no rales, rhonchi or wheezes. There is no respiratory distress.
CARDIOVASCULAR: Regular rate and rhythm without murmur, rubs, clicks, or gallops. Normal S1 and S2.
ABDOMEN: Abdomen is nondistended. There is no palpable tenderness. There is no rebound or guarding. There is no palpable mass. Bowel sounds are present and equal throughout.
PELVIS: Stable to rock. There is no visible trauma.
MUSCULOSKELETAL: There are no deformities to the extremities. Capillary refill is less than two seconds to nail beds of the bilateral hands. There is no clubbing, cyanosis or edema. Radial pulses are +2/4 bilaterally.
NEUROLOGIC: The patient is alert and oriented x3. No cranial nerve deficit. Motor examination reveals +5/5 strength throughout. Sensation is normal throughout. Finger-to-nose intact. Heel-to-shin intact. Negative Romberg sign. Gait and station appear normal. Visual fields are full to confrontation.
SKIN: Skin is warm and dry. There is no pallor. There are no signs of acute dermatologic abnormality. There is no rash, petechiae, purpura, or ecchymosis. There is good skin turgor.
PSYCH: The patient does not have suicidal ideation or homicidal ideation.  Mood is depressed. The patient does not have auditory or visual hallucinations. Judgment and cognition are normal.
            [preload_value] => GENERAL: Alert and oriented x3. No significant distress noted.
HEENT: Normocephalic, atraumatic.  Pupils are 3mm equal round and reactive to light.  Nares are patent, without epistaxis.  There is no rhinorrhea.  Pharynx is moist and without erythema, exudate, or edema.  Uvula is midline.  Tympanic membranes are clear bilaterally.  There is no hemotympanum.
NECK: Supple, trachea is midline.  There is no JVD or carotid bruits.  There is no stridor.  There is no midline or paraspinal tenderness to palpation. There is no lymphadenopathy.
BACK: There is no midline or paraspinal tenderness to palpation, no evidence of trauma, there is no CVA tenderness.
CHEST: Symmetric, there is no crepitus. There is no visible evidence of trauma to the chest. 
LUNGS: Breath sounds are present and equal bilaterally, there are no rales, rhonchi or wheezes. There is no respiratory distress.
CARDIOVASCULAR: Regular rate and rhythm without murmur, rubs, clicks, or gallops. Normal S1 and S2.
ABDOMEN: Abdomen is nondistended. There is no palpable tenderness. There is no rebound or guarding. There is no palpable mass. Bowel sounds are present and equal throughout.
PELVIS: Stable to rock. There is no visible trauma.
MUSCULOSKELETAL: There are no deformities to the extremities. Capillary refill is less than two seconds to nail beds of the bilateral hands. There is no clubbing, cyanosis or edema. Radial pulses are +2/4 bilaterally.
NEUROLOGIC: The patient is alert and oriented x3. No cranial nerve deficit. Motor examination reveals +5/5 strength throughout. Sensation is normal throughout. Finger-to-nose intact. Heel-to-shin intact. Negative Romberg sign. Gait and station appear normal. Visual fields are full to confrontation.
SKIN: Skin is warm and dry. There is no pallor. There are no signs of acute dermatologic abnormality. There is no rash, petechiae, purpura, or ecchymosis. There is good skin turgor.
PSYCH: ***
        )

    [10] => Array
        (
            [question] => ED COURSE:
Orders
            [answer] => Labs
            [preload_value] => 
        )

    [11] => Array
        (
            [question] => Lab Results
            [answer] => Opioids
            [preload_value] => 
        )

    [12] => Array
        (
            [question] => Procedures
            [answer] => None
            [preload_value] => None
        )

    [13] => Array
        (
            [question] => Calls/Consults/Rechecks
            [answer] => ***: Discussed the patient’s case with Dr. Wallis (Psych). He will admit the patient. 

***: Rechecked patient who is resting comfortably. Lab results were discussed. The patient admits to using his roommate’s pain pills. The plan for admission under the care of Dr. Wallis (Psych). Patient agrees with plan. All questions were addressed.
            [preload_value] => 
        )

    [14] => Array
        (
            [question] => Medical Decision Making
            [answer] => The patient is a male who presents to the emergency department for a psych evaluation. Medical records were reviewed. Lab work was ordered and reviewed. Findings stated above. The patient was admitted under the care of Dr. Wallis (Psych) with a diagnosis of depression. The patient's vital signs and condition remained stable while undergoing evaluation in the Emergency Department. The patient agreed with the plan for care.  All questions and concerns were addressed.
            [preload_value] => The patient is a @AGE@ @SEX@ who presents to the emergency department with a chief complaint of ***.  Medical records were reviewed. Multiple diagnoses were considered.  Lab work was ordered and reviewed. A *** was also ordered and reviewed. Imaging shows ***.  The patient was provided with *** resulting in *** of symptoms. The patient was diagnosed with ***. The patient was advised to ***. It was recommended for the patient to follow up with ***.  The patient was prescribed ***.  The patient's vital signs and condition *** while undergoing evaluation in the Emergency Department. The patient*** agreed with the plan for care.  All questions and concerns were addressed.
        )

    [15] => Array
        (
            [question] => Final Impression
            [answer] => Depression
            [preload_value] => 
        )

    [16] => Array
        (
            [question] => Plan
            [answer] => The patient is admitted under the care of Dr. Wallis (Psych) in stable condition and does not have any further questions or concerns.
            [preload_value] => 
        )

)

This content is protected, please and enroll course to view this content!