Assignment 2: Comprehensive Psychiatric Evaluation and Patient Case Presentation

My Patient Case Study:

Patient is 27 years old, African American female.

Allergy: Antibiotic topical Neosporin (give her rash)

Medication: Birth Control Pills (Yaz), Zyprexa 5mg

When were you diagnosed with bipolar disorder: January 2020 when she was being cheated in relationships?

Any physical hospitalization: No

Family History of mental illness: Both parents have dementia.

She started Zyprexa 5mg by mouth QHS in March 2020.

History of Trauma: Mom had stroke when she was 11 years old and have to take care of her.

Any issues of alcohol abuse: Drank heavily from age 21-23 but now she doesn’t drink that much anymore since she started on medication. She only drink one or three per week now.

Any legal issue: None

She started having emotional breakdown before teaching and crying before class that is when she started her on the medication.

Any feeling of sadness: Yes.

Any crying spells: Not recently.

How is your energy: Low energy now because of her mom issues.

Sleep: Good

Appetite: Not great

Isolation: No because she teach the class.

Irritability: None

Mood swing: None

Race and thought: None

Any point you think you need more time to sleep: No

Anxiety symptoms: Little bit at night. Sometimes she finds it difficult to sleep.

Any OCD: No

Psychosis History: Sometimes hearing soft voice

Any visual hallucination: No

Feeling things: No

Paranoia: None

Delusional thought: None

Feeling of hopeless and helpless: Yes. Because she feel no one can help her. She feels she needs to be producing more.

Any thought of hurting yourself: Before but not now

Any thought of hurting others: No

She was born and raised in New York, recently moved to Maryland in August 2018. She lives in Baltimore and mother lives in New York.

Marital Status: Single but lives with 2 roommates.

Parents are not married.

Siblings: one sister who is 42 years old and other 4 on the father sides.

How the relationships with mom is: Complicated because she doesn’t like no body to provide care for her.

Father: Because of dementia they are not close and he never told his family she existed.

Relationship with her sister: Not great because they see things differently.

Level of education: Master’s and teach at Towson University.

Goals: Organized, work as full time professor, feel happy and stability, and able to do things.

Diagnosis: Patient have bipolar disorder.

New medications: Prozac 20 mg by mouth daily and continue on Zyprexa 5mg PO daily and F/U in 2 weeks.