Comprehensive Psychiatric Evaluation and Patient Case Presentation
Catherine2
ClinicalComprehensiveEvaluation...docxInitial Eval. 09/21/2021
CC (Chief Complaint) The patient stated, "I have lots of pressure at home and at work".
VITAL SIGNS
Height: 5’6”
Weight: 272 lbs.
Blood Pressure: 132/68
Temperature: 97.3
Pulse: 76
Respiratory rate: 18
O2 Saturation: 98
Pain: No pain
Diagnosis: Major Depression disorder, Insomnia
Allergies: Patient has no known drug, food, or environmental allergies
Medications
Mirtazapine 15 MG Oral Tablet
Take 1 tablet (15 mg) by mouth daily at bedtime.
Smoking history: Non-smoker
Gender identity: Female
Sexual Orientation: Heterosexual
Social history: Working for 17 years. Has a good relationship with peers.
Past Medical History: Mood issue.
Ongoing medical problems: Problems in the house.
Family health history: Brother has mood problems.
No other family member has any disorder.
Preventive care: Lives with her children.
Nutrition history: Eats poorly
Developmental history: Normal birth.
Subjective:
Patient is a 41-year-old Hispanic female who has been presented for initial evaluation with consent. Weight: 272 lbs. Height: 5'6". Patient stated, "I have pressure at home and at work". She reported, "I don't feel very good, I concentrate at work, but I don't get enough sleep, and I barely eat much". She reported that her mood goes up and down, and sometimes she cries herself to sleep. She stated that she resides in the state of Maryland with her 4 children, ages 21-, 13-, and 6-years old tweens, and raising them alone. She reported that she is married, but husband is still in their country (Mexico). She reported that she has been struggling with this issue for sometimes now. She stated that she resides in the state of Maryland.
Objective:
Further evaluation of mental status reveals the following:
MENTAL STATUS EXAMINATION
General appearance: Appropriate, calm and cooperative with good eye contact.
Attitude: Good
Behavior: normal
Speech: Normal
Mood: Anxious
Affect: Euthymic
Thought Process: Goal directed
Thought Content: Normal
perceptions: Fair
Insight: Very good insight
judgment: Good
cognition: Good
Memory: Intact
Assessment:
The patient is a 41-year-old female that presents today for an initial evaluation via telehealth, consents obtained.
Patient described her chief complaint as having lots of pressure at home and at work. She reported not sleeping good at all, and barely eat each day. She stated that she cries herself to sleep most of the time. After assessing patient, provider diagnosed patient for major depressive disorder and patient stated, "you are 100% correct". Provider prescribed Mirtazapine 15 mg for depression, also to aide in insomnia. She is educated on the importance of taking her medication as prescribed. She was encouraged using coping skills to help stabilize her mood and life style change (e.g., walking, exercise, eating right, drinking lot of water). She was also educated on the medication, its interactions, and side effects, and she verbalized understanding. Patient verbalized that she has no further concerns at this time. Provider will fill the medication at the preferred pharmacy, and she is instructed to pick it up from the pharmacy. Provider recommended therapy and patient agreed. Follow up visit in 2 weeks on 10/5/2021.
Patient is encouraged to call 911 for suicidal or homicidal ideation.
Plan of Care
The plan is to maintain stability from depression, poor appetite and insomnia over the next 90 days
Continue Mirtazapine 15 mg
Educated on medication and medication interactions.
Educated on the use of positive coping skills.
Instructed to report any medication side effects or drug interactions. Verbalized understanding.
Encourage to engage in healthy lifestyle
Medication is sent to pharmacy
Follow up in 2 weeks on 10/5//21 at 3:30 pm.
Call 911 for suicidal or homicidal ideation.
Medications: Mirtazapine 15 MG Oral Tablet
Take 1 tablet (15 mg) by mouth daily at bedtime
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