Mock Patient Interview Documentation for Medical Record - 2012
Patient: Latonya C. Diaz MRN: 7778899 Date of Birth: March 1, 1974 Provider: J. Weiss, PhD, Psychologist March 10, 2012 (11:00 – 11:55 am)
Latonya Diaz is a 38 year-old single mother (7 year old son) who is being evaluated for treatment for chronic HCV infection. She has a history of intravenous drug use and has never been treated for HCV infection before. She has genotype 1 infection; was evaluated to be at stage 2 on liver biopsy several years ago; current HCV viral load is above 1 million. She is being treated for hypertension (blood pressure at visit was 150/95) and depression.
Mental Status: She is fully oriented and alert, neatly dressed and groomed, cooperative and easily engaged. She is attentive, eager to obtain advice and reassurance. She displays a range of appropriate affect during the interview, largely characterized by depressed and anxious mood including at times becoming tearful. There is no unusual speech or motor behavior. There is no unusual thought content or process. There is no current suicidal or homicidal ideation, intent or plan. She displays good insight and judgment.
Ms. Diaz was evaluated for her psychosocial readiness to begin HCV treatment in the following 9 areas of functioning:
She is interested in HCV treatment in order to ‘be more healthy’ and to make sure she does not die from HCV as she wants to be alive to take care of her son. She does have concerns about the side effects of treatment, particularly in terms of how it will impact her ability to care for her son. On a scale of 1 (not important at all) to 7 (extremely important), she rates her motivation to begin treatment as a 5.
She is aware that there are 3 medications that will be used to treat her chronic HCV infection and that one is an injection, but she does not know their names or frequency of dosing. She is aware of the length of treatment, some potential side effects, and the goal of treatment. She does not know her genotype, HCV viral load, or stage of liver disease. She was open to being further educated about HCV treatment and her liver disease status.
(3) Medication Adherence:
She is prescribed two medications to take once daily – escitalopram (Lexapro) for depression and a high blood pressure medication she does not know the name of. She is also prescribed zolpidem (Ambien) to take as needed for insomnia. In the last month, she has taken the escitalopram about 80% of the time. She tends to miss this medication due to being busy with her son and being tired (falling asleep prior to her evening dose). She has the idea that she only needs to take her high blood pressure medication when ‘I feel that my pressure is high’ and she has taken it about 60% of the time in the last month. She has never taken a prescribed medication three times per day and thinks that this would be ‘a lot’ to do. She is also concerned about the dietary requirement to eat food with the HCV protease inhibitor three times a day as she has the idea that her escitalopram ‘is already making me big.’
Her self-efficacy for being able to adhere to HCV treatment is not sufficiently high and her self-report is quite low in the event that the treatment side effects begin to interfere with her daily activities. She is most concerned about treatment side effects interfering with her ability to care for her son. While she ‘has never liked needles’ and has had others inject intravenous drugs for her, she believes that she would be able to self-inject interferon. She has fond memories of her grandmother which include observing her self-injecting insulin for her diabetes.
(5) Social Stability and Support:
She is not experiencing any problems with money, health insurance or benefits and does not have concerns about the cost of treatment. Money, however, is tight and it would be difficult for her to cut down on her current 15-20 hours per week of work during treatment (‘I only get paid the hours I work’). Her housing is stable. She is responsible for taking care of her son and has little help in doing so and is very concerned that side effects of treatment will interfere with her ability to care for him. She has told her mother and her best friend that she has chronic hepatitis C infection and they are supportive of her starting HCV treatment but also have concerns about the side effects. She has not yet told a man she has recently started dating that she has chronic HCV infection and prefers not to do so at this time. She believes that she would have some emotional support from her mother and best friend but they do not live nearby so she does not think she would have much practical support. She does have a female sponsor in NA. She does not know anyone who has been on HCV treatment.
(6) Alcohol and Substance Use:
She has not used alcohol/beer, marijuana or other illegal or non-prescribed pills in the last year. She did briefly relapse with cocaine, crack cocaine and heroin use 7 months to 1 year ago around the time that her son’s father died and she lost her job. She only used each of these drugs 1 or 2 times, with the heroin intravenously. She currently attends NA meetings once per week and speaks to her sponsor 1-2 times per week.
(7) Psychiatric Stability:
Ms. Diaz is currently well engaged in mental health treatment. She sees a psychiatrist once monthly who prescribes escitalopram for depression and zolpidem as needed for sleep. She also sees a psychologist once weekly. She feels that this treatment is adequate at this time to address her depression. There have been several days in the last month that she felt depressed and currently reports feeling worried all the time, particularly about her son. She does not currently report irritability, panic attacks, or suicidal ideation. She has a history of a suicide attempt by overdose 13 years ago at age 25 when her father died. This led to her being psychiatrically hospitalized.
(8) Energy Level:
She reports adequate sleep on 3 of the last 7 nights and using zolpidem approximately 4 nights per week. While she does report moderate fatigue, she pushes herself to do what she needs to during the day and does not feel that the fatigue interferes with her daily functioning.
(9) Cognitive Functioning:
English is her primary language and she does not have any problems communicating with health care providers. She does sometimes need help reading written instructions from the doctor or pharmacy. She reports having difficulty reasoning and solving problems ‘a little of the time’ and forgetting things ‘a good bit of the time’.
Ms. Diaz’ functioning in all 9 domains assessed is rated as ‘Could be Improved’ rather than ‘Satisfactory.’ While she is a good candidate for HCV treatment from a psychosocial perspective, she would stand a better chance of succeeding on HCV treatment if efforts are made to improve her functioning in all assessed domains prior to HCV treatment initiation. There is overlap in the issues that are negatively impacting her functioning in these areas. The most prominent issues that should be addressed are:
- Ms. Diaz’ minimal social support and the stress this places on her.
- Ms. Diaz’ current level of depression, anxiety, and insomnia.
- Ms. Diaz’ current adherence to her prescribed medications.
- Ms. Diaz’ low perceived self-efficacy in relation to HCV treatment.
- This psychologist will contact Ms. Diaz’ psychiatrist and psychologist to (1) Obtain their assessment of her readiness to begin HCV treatment and discuss strategies to help improve her level of depression, anxiety and insomnia prior to treatment initiation; (2) Obtain their consent to this psychologist joining the treatment team to provide Ms. Diaz with targeted behavioral intervention focused on HCV treatment readiness.
- Encourage Ms. Diaz to attend the next patient support group and help her arrange for child care in order to to do so.
- Have one of our program peers, if possible one who is a single mother, contact Ms. Diaz to arrange for individual meeting and enrollment in peer program.
Schedule Ms. Diaz for follow-up meetings at clinic with this psychologist to:
- Address incorrect beliefs about use of medications. Educate regarding appropriate use of antihypertensive medication and how current use is related to current blood pressure (150/95). Have her self-monitor changes in blood pressure as she begins to adhere to once daily antihypertensive medication.
- Further assess substance use history and triggers for relapse.
- Further assess opportunity to increase social support (best friend, boyfriend, mother, NA sponsor) and potential threats in her support system given her sensitivity to loss in the past (relapse when son’s father died; suicide attempt when her own father died).
- Further assess basis for low self-efficacy by exploring her coping style and resources.
- Schedule adherence visit with nurse to provide adherence counseling and tools in light of self-reported memory problems.
- Repeat PREP-C prior to HCV treatment initiation.