Care Across the Lifespan I
Tinacherry100$
w.3.Case1.docxCase
G.C 17-year-old Female
Medications(Active)
· OXcarbazepine 150 mg tablet
· buPROPion HCL XL 150 mg 24 hr tablet, extended release
· traZODone 50 mg tablet
Problems(All Active)
· Social phobia (disorder)
· Attention deficit hyperactivity disorder, combined type (disorder)
· Insomnia (disorder)
· Generalized anxiety disorder (disorder)
· Severe mood disorder with psychotic features (disorder)
· Posttraumatic stress disorder (disorder)
History(Summary)
· PMHx
· Comments: Heart murmur as baby
· PSHx
· Comments: No surgical history
· FHx
· Comments: Mother (living)- GAD, Bipolar disorder, depression Father (living)-unknown Maternal grandmother- (living) Bipolar Disorder
· SHx
· Tobacco: Never smoker
· Alcohol: Do not drink
· Drug Abuse: Illicit drug use - "I smoke four days a week."
· Safety: Wear seatbelts
· Sexual Activity: Sexually active
· Birth Gender: Female
· OB & Preg Hx
· Ob History: Age of menses: 14
· Hospitalizations / Procedures
· No hospitalizations / procedures have been documented for this patient
· Long Term Care Facility
· No Long Term Care Facilities have been documented for this patient
· Hospice
· No hospices have been documented for this patient
· Implantable Devices
· No implantable devices have been documented for this patient
New Psychiatric Admission
Individual is alert and oriented x 3. She is calm and cooperative. She is accompanied by mother and sister. Mother reports that individual has anxiety and difficulty focusing. "I have mood swings. Sometimes my highs are too high and my lows are too low." Individual reports that she does not sleep. "I can go to sleep but falling asleep is hard." Individual rates life 7/10, with 10 being total happiness. Individua denies SI/HI. Her last suicidal thoughts were eight months ago. Individual has a diagnosis of Bipolar disorder and Generalized Anxiety Disorder. Individual reports that she has been on Adderall, Venlafaxine ER 75 mg daily, oxcarbazepine 150 mg twice daily and fluoxetine 10 mg daily. Individual reports that she sees shadow in the corner of the room. She hears voices at times. "They start getting louder in my ear. Sometimes, it's hard to differentiate between intrusive thoughts or voices." Individual reports that she has these thoughts or visions when she is down. Individual reports that she only eats once every two days. Individual reports that she has panic attacks.
Individual reports hospital inpatient visit on 2022. "I really couldn't get out of my low. It was getting dangerous because I couldn't get out of it. I would say anxiety and mood swings started my seventh grade summer." Individual reports verbal, emotional, sexual, and physical trauma from ages 5-9.
· Comments: Heart murmur as baby
· Comments: No surgical history
· Comments: Mother (living)- GAD, Bipolar disorder, depression Father (living)-unknown Maternal grandmother- (living) Bipolar Disorder
· Tobacco: Never smoker
· Alcohol: Do not drink
· Drug Abuse: Illicit drug use - "I smoke four days a week."
· Safety: Wear seatbelts
· Sexual Activity: Sexually active
· Birth Gender: Female
· Ob History: Age of menses:14
· 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
·
|
OXcarbazepine 150 mg tablet, Take one tab twice daily |
·
|
buPROPion HCL XL 150 mg 24 hr tablet, extended release, Take one tab daily |
·
|
traZODone 50 mg tablet, Take one tab nightly |
No known allergies
GAD-7- 17, PHQ-9- 20, MDQ- (+)
29 Aug 2022 - 10:55 AM - recorded by KIMBERLY NATSON
BP:
144.0 / 100.0
HR:
87.0 bpm
Temp:
97.8 °F
Ht/Lt:
5' 8"
Wt:
190 lbs 0 oz
BMI:
28.89
Comments: pain- 0/10
Social phobia (disorder) (F40.11/300.23) Social phobia, generalized modified 29 Aug, 2022
Attention deficit hyperactivity disorder, combined type (disorder) (F90.2/314.01) Attention-deficit hyperactivity disorder, combined type modified 29 Aug, 2022
Insomnia (disorder) (G47.00/780.52) Insomnia, unspecified modified 29 Aug, 2022
Generalized anxiety disorder (disorder) (F41.1/300.02) Generalized anxiety disorder modified 29 Aug, 2022
Severe mood disorder with psychotic features (disorder) (F31.5/296.54) Bipolar disorder, current episode depressed, severe, with psychotic features modified 29 Aug, 2022
Posttraumatic stress disorder (disorder) (F43.12/309.81) Post-traumatic stress disorder, chronic modified 29 Aug, 2022
Start bupropion 150 XL daily, start oxcarbazepine 150 mg twice daily, start trazadone 50 mg nightly. Monitor for and report any side effects. Call 911 or visit hospital in case of emergency. Follow up in 4 weeks. Individual and mother verbalize understanding of treatment plan.
"I want to be better."
