Care Across the Lifespan I

Individual is alert and oriented x 3. Individual is seen face to face in clinic for psychiatric evaluation. Individual is accompanied by grandmother. Individual is a trans male. He used the pronouns he/him. He also goes by Paul. "I am pretty mentally ill. I did have a psychiatrist. I have been trying to advocate for myself and trying to change my medications. She doesn't listen. I currently take four medications. I take buspirone 10 mg TID, olanzapine 15 mg nightly, Wellbutrin 100 mg daily, Effexor 150 mg daily." Individual has been diagnosed with depression, anxiety, autism, ADHD and PTSD. Individual reports that he has been sleeping ok. "Some nights are better than others." Individual currently rates life 6/10, with 10 being total happiness. Individual denies SI/HI. Individual reports that he experiences psychotic symptoms like hallucinations on daily basis mostly when he is depressed. "The symptoms are less intense when I'm on the olanzapine." Individual reports that he has bouts of highs and lows often. 

Individual goes by Paul. Individual is alert and oriented x 3. Individual reports that things have not been good. "I have been experiencing more symptoms.  Individual reports that he has been dealing with side effects. "I haven't been able to regulate body temperature. I have been really moody. I have also had sexual side effects. I cut my olanzapine in half." Individual reports that he is about to begin counseling with a new agency. Individual denies SI/HI. Individual reports that he experiences few hallucinations. Individual reports that he has experienced more lows. 

Individual reports that he has been dealing with mental health illnesses all of his life. Individual was emotionally, physically and verbally abused when he was a child by father and grandmother. 

· Depression

· Comments: Anemia in past, hypermobility

· Comments: No surgery

· Comments: Mother (living)- Bipolar disorder, uterine cancer Father (living)- depression, anxiety, autism

· Tobacco: Never smoker

· Alcohol: Occasional drink

· Drug Abuse: Illicit drug use - Marijuana weekly

· Birth Gender: Female

· Ob History: Age of menses:9

· No implantable devices has been documented for this patient

Psychiatric: (+)change in mood, (+)depression, (+)sadness interfering with function, (+)anxiety, (+)nervousness, (+)sleep disturbance, (+)suicidal ideation, (+)hopelessness, (+)worthlessness, (+)delusions, (+)hallucinations

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Paxil (Unknown) - mental state / behavior / psychosocial finding;

zithromyocin (Unknown) - nausea / vomiting;

GAD-7 total score: 14 PHQ-9 total score: 21, MDQ (+)

Ht/Lt:

5' 2"

Wt:

185 lbs 0 oz

BMI:

33.84

Comments: pain- 0/10

Assessment

Moderate bipolar disorder (disorder) 

Posttraumatic stress disorder (disorder) 

Plan

Continue olanzapine 10, start Effexor 75 mg. Continue Wellbutrin 100 mg. At next visit continue venlafaxine taper, start bupropion taper. Look into introducing Latuda.  Monitor for and report any side effects. Call 911 or visit hospital in case of emergency. Follow up in 4 weeks. Individual and grandmother verbalize understanding of treatment plan.