Unit 4 – ROOT CAUSE ANALYSIS WORKSHEET Student Name: Ochuko

REGO HEALTH SERVICES 753 FREUDIAN WAY • SOMEWHERE, FL 32811 • 407-555-5577 PATIENT:​HOUSTON, BART ACCOUNT/EHR #:​HOUSBA001 This new patient is a 31-year-old male who presents in my office with complaints of fatigue and sleeplessness. He was last seen by his family physician, Dr. Crane, 1 year ago following minor MVA. PMH/PSH: Three grand mal seizures as a child—none since age 12 ACL repair—age 19 Appendectomy—age 26 SOCIAL HX: Married 7 years with a 5-year-old daughter, employed as a chef in a small neighborhood restaurant for the past 2 years, drinks a “few” beers on the weekend, smokes one pack of cigarettes per day since the age of 18, denies current or history of illicit drug use. Patient states that he hasn’t been sleeping, he’s always tired, and he has experienced some weight loss recently. His cousin was just diagnosed with lung cancer, and the patient is worried about getting the condition; however, not worried enough to quit smoking. REVIEW OF SYMPTOMS: Patient denies any change in his usual morning cough and hemoptysis (helping to lower the concern for lung cancer), palpitations and heat intolerance (helping to rule out hyperthyroidism), nausea, vomiting, diarrhea, melena, or hematochezia (helping to rule out GI causes of weight loss). He is not taking any medication. He is not trying to lose weight. Patient does acknowledge feeling depressed over the past month, stating “it just kept getting worse and worse.” He has lost interest in playing on his softball team and has missed the past five games. He also says that when his daughter asks him to play, he is reluctant to do so because he doesn’t want her to see him “like this.” He feels sluggish and tired and states it all seems “worthless—like things will never get better.” He denies the symptoms of mania. PAST PSYCHIATRIC HISTORY: The patient describes passive thoughts of dying, sleep disturbance and feelings of worthlessness. He states these symptoms lasted “a few months” and went away after his family physician prescribed “a pill that helped me sleep.” He also acknowledged depressed mood, anhedonia, and decreased energy while his wife was pregnant with their daughter. He states that he sought no treatment for these symptoms, which resolved over three or four months. He states that he has never been evaluated by a psychiatrist. He has never participated in counseling or therapy. There is no history of psychiatric hospitalizations, and he denies a history of suicide attempts. FAMILY PSYCHIATRIC HISTORY: The patient’s mother “used to take something for her nerves.” There is no FHx of psychiatric hospitalizations or suicide attempts. DX: Depression PLAN: Begin patient with cognitive therapy. In addition, recommendation is made for family therapy to help the patient and his wife create a positive social support network. Marlon Carroll, MD

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