CASE STUDY 4 - Depression, Anxiety, Substance Use, and Chronic Pain Case Scenario Ms. R.D. is a 45-year-old female presenting with insomnia, fatigue, chronic low back pain, and mood changes.
Advanced Primary Care of Family I-HBN-HY01 Luis Serrano 5 pages
🩺 CASE STUDY 4: Depression, Anxiety, Substance Use, and Chronic Pain
CASE STUDY 4 - Depression, Anxiety, Substance Use, and Chronic Pain
Case Scenario
Ms. R.D. is a 45-year-old female presenting with insomnia, fatigue, chronic low back pain, and mood changes.
History
- PMH: Chronic pain, prior opioid exposure
- Reports alcohol use nightly
- PHQ-9: 17, GAD-7: 15
Student Assignment Requirements
1. Pathophysiology (25%)
- Neurobiology of depression and anxiety
- Substance use impact on CNS
- Pain–mood interaction
2. Mental Health Assessment (35%)
- Diagnostic differentiation
- Suicide risk screening
- Substance use screening
- Safety planning
3. Pharmacology & Integrated Treatment (30%)
- Antidepressant selection and titration
- Avoidance of high-risk medications
- Non-pharmacologic and referral planning
4. APA & Evidence Use (10%)
RUBRIC – CASE STUDY 4 - Mental Health, Substance Use & Chronic Pain (100 Points)
1. Neurobiologic Pathophysiology (25 points)
|
Level |
Description |
|
Excellent (23–25) |
Integrates neurobiology of mood disorders, substance
use, and pain with strong application to clinical symptoms. |
|
Satisfactory (18–22) |
Accurate explanation with limited integration. |
|
Unsatisfactory (13–17) |
Partial or unclear explanation. |
|
Poor (1–12) |
Incorrect or superficial discussion. |
|
Not Submitted (0) |
Section not submitted or missing. |
2. Mental Health & Safety Assessment (35 points)
|
Level |
Description |
|
Excellent (33–35) |
Comprehensive assessment including diagnostic
differentiation, suicide risk, substance use screening, and safety planning. |
|
Satisfactory (26–32) |
Assessment is appropriate but lacks depth or clarity
in prioritization. |
|
Unsatisfactory (18–25) |
Incomplete assessment or missed safety considerations. |
|
Poor (1–17) |
Unsafe or inadequate evaluation. |
|
Not Submitted (0) |
Section not submitted or missing. |
3. Pharmacology & Integrated Care Plan (30 points)
|
Level |
Description |
|
Excellent (28–30) |
Evidence-based medication selection with safe
prescribing, clear rationale, and integrated non-pharmacologic strategies. |
|
Satisfactory (22–27) |
Appropriate plan but lacks optimization or monitoring
detail. |
|
Unsatisfactory (16–21) |
Limited pharmacologic understanding or justification. |
|
Poor (1–15) |
Unsafe or inappropriate treatment decisions. |
|
Not Submitted (0) |
Section not submitted or missing. |
4. APA & Scholarly Writing (10 points)
(Same descriptors as Case 1)
Submission
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