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: