A
Decline. Without a release you cannot speak with the partner at all, and meeting them first would compromise the patient's confidentiality.
BH
Brooke Harbor Health System
PMHNP Clinical Learning Environment
Grand Rounds · 12:00 · Brooke Auditorium
Grand RoundsCase-based clinical reasoning within the BHHS training environment.
Anxiety, or something else?
A session on the foundations: consent and collateral, the medical differential, and where findings actually belong in the note. Three decision points. Commit to an answer before reading past each one.
The referral
Outpatient Behavioral Health, new patient, 60 minutes
A 34-year-old is referred by primary care for six months of anxiety and difficulty concentrating. The referral notes poor sleep, irritability, palpitations, and feeling on edge, and mentions recent job stress. The patient has lost weight without trying. There is no psychiatric treatment history. They take an over-the-counter supplement bought online for energy and metabolism.
Their partner has come to the appointment and asks the front desk whether they can speak with you privately, before you see the patient.
Decision point 1
The partner wants to talk first
You have not met the patient yet. Decide before reading on.
B
Meet the partner privately and agree to keep what they say between the two of you, so they feel able to be candid.
C
Tell the partner you can listen but cannot promise confidentiality or share information back, then raise with the patient that the conversation happened.
C. Receiving information and disclosing information are governed differently. You can listen to collateral without the patient's authorization, because nothing about the patient is being revealed by listening. What you may say back is what requires authorization, which is why A is too restrictive and would discard useful history.
B is the trap. A promise of secrecy to a third party is one you cannot reliably keep, it creates an alliance the patient is not part of, and it will damage the relationship the moment the patient learns of it. Tell the partner what you can and cannot do before they start talking, not after. Then tell the patient that the contact occurred, and generally what was said, unless a specific safety reason argues otherwise.
Decision point 2
Before you name an anxiety disorder
The partner describes irritability that is new, and says the patient is up at night and has lost noticeable weight. On examination the patient is restless and warm, with a heart rate of 112. Decide what you do next.
A
Diagnose generalized anxiety disorder, start an SSRI, and arrange follow-up in four weeks to assess response.
B
Complete a psychiatric review of systems and a medical review, review the supplement's actual ingredients, and order targeted laboratory work before assigning a diagnosis.
C
Refer back to primary care for medical clearance and defer psychiatric assessment until that is complete.
B. Ordering and interpreting diagnostic tests is within PMHNP scope, and this presentation calls for it. Six months of anxiety with unintentional weight loss, tachycardia, heat intolerance, and new irritability is not a typical anxiety picture, and the supplement is an unquantified exposure until someone reads the label. Thyroid function testing is the obvious first step here, alongside a metabolic panel, complete blood count, and consideration of substance use.
A treats the referral question as the diagnosis. C is not wrong so much as it is an abdication: sending the patient away without doing the assessment you are trained to do delays care and misrepresents your scope. Refer for management of what you find, not for permission to assess.
Decision point 3
Where does each finding belong?
You have six findings. Sort each into Subjective, Objective, or Assessment before reading the third column.
FindingSectionWhy
Six months of feeling on edge, worse over the last two monthsSubjective · HPIThe patient's own account of symptoms and timeline.
Partner reports the patient has been snapping at their children, which is new for themSubjective · HPICollateral history is still history. Attribute it to its source rather than presenting it as your observation.
Restless throughout the interview, repeatedly repositioning, unable to remain seatedObjective · MSEWhat you observed during the encounter.
Heart rate 112, weight 14 pounds below the value recorded eight months agoObjective · vitalsMeasured data, not interpretation.
Attention intact on serial subtraction; no perceptual disturbance elicitedObjective · MSEA pertinent negative you tested for is an objective finding, not an absence worth omitting.
The symptom pattern and physical findings are more consistent with a medical contributor than a primary anxiety disorderAssessmentThis is your reasoning. It does not belong anywhere above.
The recurring error is letting interpretation drift upward into the history. "Patient is anxious" in the HPI is a conclusion wearing the clothes of a report. Write what the patient said, write what you observed, then say what you think it means and keep those three apart.
How the case resolves
The anxiety was real; the cause was not psychiatric
Thyroid studies return with a suppressed TSH and an elevated free T4. The supplement contains caffeine and a stimulant botanical, which is contributing to the tachycardia and insomnia but does not account for the whole picture. The patient is referred for management of hyperthyroidism, advised to stop the supplement, and kept in psychiatric follow-up, because six months of severe anxiety leaves its own marks and because the symptoms will not resolve the day treatment starts.
Note what did not happen. No anxiety disorder was diagnosed and then undiagnosed. The medical differential was worked before a psychiatric label was assigned, which is the sequence that keeps a wrong diagnosis out of the chart in the first place.
Take it further
Where to read more
Ruling Out Medical Causes
Structured approach to medical, medication-related, and substance-related contributors. Open resource →
Psychiatric Interview & History
History domains, collateral, and structured cultural assessment. Open resource →
Mental Status Examination
What belongs in the MSE and how to write it objectively. Open resource →
Documentation
Note structure, objective language, and separating findings from interpretation. Open resource →
Legal & Ethical Dimensions
Consent, confidentiality limits, collateral contact, and disclosure. Open resource →
Anxiety Disorders
Diagnostic criteria, differential considerations, and treatment. Open guide →