Vignette – You are seeing a patient 38-year-old female, you are aware that she has a significant problem with meth abuse that you have been working on. She also has a violent tendency. Today she comes in with her daughter that is 8 years old. She appears cold and lacks maternal boding. She yells at the daughter throughout your visit. The daughter spends most of the time crying. She grabs the child’s arm forcefully and then storms out. You did not see anything that the daughter was doing to elicit this kind of response from the patient. They leave and you are left with an uneasy feeling. What will you do
HPI: in your own words do not copy and paste.
Diagnosis: talk about the diagnosis you feel is presented with evidence on why you feel it is that dx.
Differential: differentials that may be pertinent (3), why they fit and how you ruled them out.
Treatment: be specific about what medication, dose and duration and evidence base on why the medication was chosen. Other non-pharmacological tx also presented.
Education: discuss education to patient, evidence based.
