Comprehensive Psychiatric Evaluation and Patient Case Presentation
Catherine2
NEWPATIENTCLINICALDOCUMENTATION.docxPATIENT EVALUATION
SUBJECTIVE
OBJECTIVE
The patient is alert and oriented x 4, to person, place, time and situation. Vital signs: T=97.6, B/P=128/72, P=72, R=18, oxygen saturation=97%, Ht.=5’9”, Wt.=138lbs. She appeared very neat and clean. She has normal eye contact, psychomotor is normal, cooperative with the provider. The patient reported that she need help and that she doesn’t have any motivation to live. She reported that she does not feel suicidal any longer. Her speech was soft, angry and depressed mood, and her affect is manic and restricted to her mood. Patient thought process is goal directed, and thought content was circumstantial. She has a fair insight and judgment. The patient denied any suicidal or homicidal ideation at this time.
ASSESSMENT
Ms. AL is a 32 years old Caucasian female seen today for initial evaluation via video conference with consent obtained with a diagnosis of bipolar disorder and depressive disorder. She reported that she needs help and that she has no motivation to live. The patient's appearance is neat and clean. She reported that she is currently taking Trileptal 600mg and Mirtazapine 15mg. She reported that she was admitted to a psychiatric facility two different times during her teenage life. She reported that she sees and talks to a therapist once a week at the mental health clinic due to the severity of her depression. She reported that she has been seeing a therapist since she was 6 years old. She stated that she dropped out of high school in 12th grade because someone put a knife on her back, and no one believed her. Stated that she was sexually and physically abused in the past. The patient stated that her mental problem affected her previous job and that she used acts out on her boyfriend, though she stated that he takes care of her and keeps her in check, along with her mother. She reported that her mother has history of Major Depressive Disorder. She also, reported that her divorce when she was 6 years old. She reported that she is currently working at Wellness Center since February 2021, and that she loves the job. Also stated that the people that she works with are good and nice. She was encouraged to use coping skills to help stabilize her mood and lifestyle change, like; walking, exercise, eating right, drinking a lot of water, and keep journal of how many hours she sleeps at night. And she verbalized understanding. She reported that she medical history of a heart murmur, ovarian cyst, and kidney problems. She stated that she was allergic to PNC. She reported that she is sexually active and does not want to have children to avoid them having mental problems. She stated that she is not pregnant, and is currently on her period. The patient verbalized having physical and lab work done recently and that she will provide them to the provider. She reported that she has been smoking marijuana since the age of 16 years old. She denied hearing voices, hallucinations, or delusions. She denied feeling suicidal or homicidal at this time.
PLAN OF CARE:
The plan of care is to decrease the sign and symptoms of major depression and bipolar disorder over 90 days period.
To continue follow up with the therapist
Educated on disease progression, to produce lab work and annual physical to the provider.
Continue on Trileptal 600mg and Mirtazapine 15mg.
Call 911 if feeling suicidal or homicidal ideation.
Follow up visit in 2 weeks on 11/2/21 at 11 AM
OBJECTIVE:
V/S: T=97.6, B/P=128/72, P=72, R=18, oxygen saturation=97%, Ht.=5’9”, Wt.=138lbs.
Mental Status Examination.
General Appearance: Neat & clean.
Eye contact: Normal.
Psychomotor: Normal.
Orientation: Person. Place. Time. Situation.
Attention: Intact.
BEHAVIOR: Cooperative
SPEECH: Normal.
MOOD: Angry. Depressed
AFFECT: Appropriate. Manic.
THOUGHT PROCESS: Goal-Directed.
THOUGHT CONTENT: Intact.
PERCEPTIONS: Good.
INSIGHT: Good. Fair.
JUDGMENT: Good.
COGNITION: Intact,
Language. Appropriate
MEMORY: Immediate. Recent. Remote.
PROTECTIVE FACTORS: "I am working at Wellness Center"
SAFETY PLAN RECOMMENDATIONS: TO CALL 911 IF FEELING SUICIDAL OR HOMICIDAL IDEATION.
Psychosis: No -Taking medication
ALCOHOL/DRUG: Social Drinking, Smokes Marijuana
PSYCHOSOCIAL: Lives with her partner at Glen Burnie, in the state of Maryland, No children, Works at Wellness Center
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MEDICATIONS: Mirtazapine 15 MG Oral Tablet Take 1 tablet (15 mg) by mouth daily at bedtime |
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Oxcarbazepine (Trileptal) 600 MG Oral Tablet Take 1 tablet (600 mg) by mouth 2 times per day |
Diagnosis Formulation: Choose the best tool below for the diagnosis:
Screening Tool: GAD, VANDERBILT-ADHD, PANSS, Brief Psychiatric Rating Scale (BPRS)
CC (Chief Complain): The patient stated, “I need help, I don’t have the motivation to live”.
