PRAC 6635 Wk 9 Assignment 2: Comprehensive Psychiatric Evaluation and Patient Case Presentation

PRAC 6635 Wk 9 Assignment 2: Comprehensive Psychiatric Evaluation and Patient Case Presentation

CC (chief complaint):”medication refill”

HPI

DM is a 30-year-old AA female who has come to the clinic for medication refill. Patient reports that she has hx of paranoia and anxiety which led to her being admitted to the hospital about a year ago. Patient reports she was diagnosed with Bipolar II depressive type at the age of 19. After the discharge from hospital patient has been on the same medications as reports on her medication list. Patient states that her medications has been filled previously in a community clinicbut they refused to refill her medications as she had missed several visits and had not seen the Doctor for a long time due to the pandemic.

Patient reports she has mood swings frequently which have been well controlled  with medication and coping skills. Patient states that she has difficulty concentrating at times and finishing tasks and her mind is racing a lot of times. Patient reports she has a  full time job but she does not feel fulfilled as she has suffered a lot of losses in the past year and has not been in a relationship or been intimate with anyone since 2019.

Patient states that she is starting to get nervous and stressed because she does not want to be out of medications and end up in hospital again. Patient reports she does not have a lot of support system and mostly keeps to her self. Patient acknowledges that she build up things and does not express her feelings freely.

Patient does not report hallucinations, delusions, obsessions, or compulsions. Patient’s activity level, attention and concentration were observed to be within normal limits. Patient does not report symptoms of eating disorder. There is no recent weight loss or gain.

Patient currently denies suicidal ideation ( had hx of suicidal attempt when pt was 13 yo), denies SIBx, denies homicidal ideation, denies violent behavior, denies inappropriate/illegal behaviors.

Past Psychiatric History: Previous psychiatric diagnoses: Bipolar disorder II depressive type ( at age 19 years old). Patient was on the reported meds for the past years.

• General Statement: 30 year old AA female here for medication refill.
• Caregivers (if applicable): No caregivers
• Hospitalizations: Manic episode- last admission was 2020 at PIW
• Medication trials: haldol, seroquel, carbamazepin
• Psychotherapy or Previous Psychiatric Diagnosis : Bipolar disorder II depressive type ( at age 19 years old). Pt was on the reproted meds for the past years.

Substance Current Use and History: Client denies use or dependence on nicotine/tobacco products.

Client does not report abuse of or dependence on ETOH, and other illicit drugs.

Family Psychiatric/Substance Use History: Bipolar from father side, no mental health from mother side. Pt is the only child. No reported knowledge of family history of substance use issues.

Psychosocial History: Occupational History: Patient is a 30 year old AA female, single, lives alone and has no social life. She is currently employed and denies military service.

Education history: started college, did not finish

Developmental History: no significant details reported.

Legal History: pt had hx of arrested but never convicted

Spiritual/Cultural Considerations: none reported.

Medical History:

• Current Medications:
• Benztropine 1 mg tablet every day by oral route at bedtime.
• Oxcarbazepine 300 mg1 tablet twice a day by oral route with meals
• Risperdal 2 mg tablet 1 tablet every day by oral route
• Allergies: Peanut

• Reproductive Hx: Menarche at 12years, regular peiods, no children

ROS:

• GENERAL: Anxious female, looks older than stated age, seeking medication refill
• HEENT: Eyes: no irritation or dry eyes.Ears: no difficulty hearing or ear pain. Mouth/Throat: no sore throat or dry mouth.
• SKIN: Skin: no jaundice, rashes, laceration, or abnormal mole
• CARDIOVASCULAR: Cardiovascular: no shortness of breath when walking or breath when lying down and no palpitations or
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