PBL Case Discussion: Behavioral Health and Cultural Diversity in Primary Care

• Part One (graded)

Setting: urban area, medium sized city

Family practice clinic near a college which employs nurse practitioners and physicians

Part 1: Your next patient is here with complaints of not feeling well.

This is the first visit for Ed, a 19-year-old student at the nearby college. You enter the room and introduce yourself to Ed. Ed is unshaven and not well groomed. He appears to be uncomfortable as he reaches forward to shake your outstretched hand and does not make eye contact.

• Part Two:

1. What is your primary diagnosis/diagnoses with ICD 10 code for Ed? Include the rationale and a reference for your diagnosis.
2. What is your first line treatment plan for Ed including medications, labs, education, referrals, and follow-up?

• SOAP Note

Ed, 19 yo, M

S.

CC: Not feeling well, having difficulty getting up for class, feeling down, fatigue

HPI: Ed states he is in general good health and denies any health conditions. He is a second semester college student with new onset fatigue and difficulty enjoying social events for the past 2 months since college classes started and decreased grades in school.....................