Comprehensive Psychiatric Evaluation and Patient Case Presentation

Patient: Ms. DYL

Chief complaint: Ms. DYL stated, “I had lots of issues at work and it was stressing me out”.

 

VITAL SIGNS

Height: 5’9”

Weight; 154 lbs.

BP: 138/76

Temperature: 97.3F

Pulse: 88

Respiratory rate: 20

O2 Saturation: 98%

Pain: No complaint of pain verbalized during evaluation.

Diagnosis: Schizophrenia.

Allergies: Patient has no known drug allergies, food or environmental allergies.

Medications:

Risperidone 2 MG Oral Tablet, take 1 tablet by mouth daily 

Fluoxetine HCl 20 MG Oral Capsule, take 1 capsule by mouth daily 

Benztropine Mesylate 1 MG Oral Tablet, take 1 tablet by mouth daily at bedtime 

Social History: Social drinker twice a year

Smoking Status:

Non-smoker 01/13/2021

Gender Identity: Female

Sexual orientation: Straight or Heterosexual

Past Medical History: Admitted to a psychiatric facility in 2018

Family medical History:

Father has dementia.

No other medical health issues reported about other family members.

Nutritional History: Has good appetite.

Developmental History: Normal birth, grew up with both parents, obtained her GED and she has 2 siblings.

 

SUBJECTIVE: 

Miss Dede Yawa Koffie-Lart is a 39-year-old female who presents for her new patient evaluation via telehealth; consent obtained. The patient stated, “I had lots of issues at work and it was stressing me out”. She stated, “I’m seeing a new psychiatrist because my previous provider no longer accepts my health insurance. The patient stated that she was diagnosed with schizophrenia in 2018 after she had an "episode". She states she was working a job and she was having issues at her job that contributed to her symptoms. She states she was admitted to a psychiatric hospital (Washington Adventist) in 2018, where she was diagnosed with schizophrenia. She was put on Zoloft 20mg and was getting injections of Aristada (Aripiprazole lauroxil) for 1.5 years. She states she stopped taking the injections as she was unable to afford it. She has recently started taking risperidone 2mg.

OBJECTIVE: 

Mental Status Examination.

General Appearance: Neat & clean.,

Eye contact: Normal.

Psychomotor Activity: Repetitive movements

Orientation: Person. Place. Time. Situation.

Attention: Intact.

           

BEHAVIOR:  Cooperative.

SPEECH: Normal.

MOOD: Euthymic.

AFFECT: Appropriate.

THOUGHT PROCESS: Goal Directed.

THOUGHT CONTENT: Intact.

PERCEPTIONS: Good.

INSIGHT: Good.

JUDGMENT: Fair.

COGNITION:  Fair.

Language. Appropriate

MEMORY: Immediate. Recent. Remote.

SAFETY PLAN RECOMMENDATIONS: TO CALL 911 IF FEELING SUICIDAL OR HOMICIDAL IDEATION.

Psychosis: Taking medication

Diagnosis Formulation: Screening Tool used PHQ

Objective:

The patient is alert and oriented x 4, to person, place, time and situation. She states she has had a hard time maintaining a job, but she is currently working for a temp agency and that is going well. She is not in a relationship. Denies any sexual activity. She states she lives alone. She states she enjoys various hobbies such as going to movies, watch TV, and shopping. She states she is a Christian.

She states that she is tolerating the medication well and she has been on this medication for a long time, even with her previous provider. Encouraged the patient to continue to take the medication as directed. Educated the patient on the side effects of the medication and advised her to report any side effects she may encounter while taking the medication. The patient verbalized understanding.

The patient has a noticeable irregular facial movement of her lower jaw. Discussed adding Cogentin to her daily medication. The patient refused at this time.

Encouraged the patient to use positive coping skills such as walking, journaling, and deep breathing exercises. Discussed positive sleep hygiene such as exercise, warm shower, no eating after 7 PM, and turning off electronics at least 2 hours before the hour of sleep.

Plan of Care: Continue to stabilize symptoms of schizophrenia in the next 90 days.

Encouraged the patient to complete a physical and get yearly labs (CBC, CMP, UA, pregnancy test)

Encouraged positive coping skills such as walking, journaling, and deep breathing exercises.

Call 911 if suicidal or homicidal

Follow-up in in 4 weeks.