RP’s Psychiatric Evaluation Note

RP’s Psychiatric Evaluation Note

Subjective:

CC: RP was originally brought into the ED by her biological mother due to needing to be checked out for a UTI.

HPI: RP is a 15-year-old Caucasian female. The patient was originally brought into the ED by her biological mother due to needing to be checked out for a UTI, the patient complained of vaginal irritation and burning with no discharge, bleeding, or odor. Earlier in the day the patient was observed by her mother masturbating with and inserting a shampoo bottle in her vagina which she denied doing when her mother confronted her about it. While waiting in the waiting with her mother, RD, was observed jumping up and running out the ED doors and attempting to run into oncoming traffic to get killed, the patient’s mother grabbed her and held her back from traffic. stating, “that I want to die”. RP, states” I see a man with a knife trying to me” The patient is then heard stating “I want to die” and then stated,” When I leave here, I will try to get hit by traffic again”. The patient denies homicidal ideation at this time. The patient states that she has had depression for a long time and anxiety since the age of 5, with self-harm by scratching, thinks about suicide every day, and has homicidal thoughts as well but to no one in particular, she also states that she hears and see things but would only talk about the man with the knife. The patient states that her mood changes a lot and that she misses her aunt who died last year. RP is an only child and lives with her mother, her primary support person, her mother’s boyfriend, and her maternal grandmother. The patient’s father is alive with a history of Bipolar with AVH, and Alcohol Abuse, and has no contact with his daughter. The patient has a history of sexual victimization by her maternal grandmother’s boyfriend. The abuse was reported, and he was sentenced to 50 years to life. The patient\’s mother states that the patient has been showing signs of inappropriate sexual behaviors for years, such as inserting foreign objects in her vagina. The mother states that the patient has had sexual aggression throughout the patient’s life, which the patient denies and a history of elopement. The patient also has no documented history of assaults and threats toward healthcare staff or others. The patient is always attention seeking states the mother and has issues with personal space and boundaries with others. The mother states that PR has poor insight, and social skills (no friends) as well as poor coping skills, is moody all the time, and sleeps all the time but always wakes up in the middle of the night. The patient is a Type II diabetic and gets her blood sugar tested regularly her last BS was 101, and RP uses metformin which she is compliant with. The patient is obese, weighing 194 lbs. and is 61 inches tall with a BMI of 36.7, and in the 99 % percentile. The patient has issues following her diabetic diet as evidenced by eating 4-5 cookies at lunch even when advised that they would make her BS go up and trying to get extra snacks in the evening from staff and other patients, the patient states that she does not like meat. The patient is in the 10th grade with below-average intelligence, poor concentration, and attention span. RP has an IEP for reading, the patient could not spell the word (world) backward, the patient reads at a 3-5 grade level and has an IEP missed numerous days of school due to mental health issues. The patient denies drinking, doing drugs, smoking, or vaping and denies any sexual relationships at this time. (include psychiatric ROS rule out)

• Past Psychiatric History: The mother states that the patient has had numerous other voluntary IP hospitalizations in the past. The patient was just admitted as an IP at another hospital four weeks before this current episode. The patient is receiving Lithium 300mg PO BID, Lithium 150mg PO QHS Daily, Effexor XR 75 mg PO QAM Daily, LaMICtal 200 mg PO BID, BusPIRone 15 mg PO BID, Venlafaxine XR 75 mg PO Daily, Melatonin 10 mg QHS PRN, Albuterol MDI (90 mcg/inh) 2 puffs Q4h PRN, Metformin 500mg PO QAM Daily. The patient is compliant with taking her medications.
• The patient has tested negative on the U pH drug Screen for Amphetamines, Barbiturates, Cannabinoids, Cocaine, Fentanyl, Benzodiazepines, Methadone Opiate, Oxycodone, PCP, Propoxyphene, and Ethanol levels <10.0 mg/dl, which shows that the patient was not under the influence of drugs or alcohol at the time of her incident in the ED. ( Reference this)
• The patient has tested negative on the U pH drug Screen for Amphetamines, Barbiturates, Cannabinoids, Cocaine, Fentanyl, Benzodiazepines, Methadone Opiate, Oxycodone, PCP, Propoxyphene, and Ethanol levels <10.0 mg/dl, which shows that the patient was not under the influence of drugs or alcohol at the time of her incident in the ED. PR’S BUN, CBC, WBC, and UA Dipstick Chemistry Profiles lab values are all within the normal range, The patient’, Urine pregnancy POC, also tested negative. ( Reference this)
• The patient\’s Lithium level is 0.58 mmoI/L, for maintenance treatment levels of Bipolar DO, the minimum effective serum lithium level for a patient should be between 0.6 – 1.2 mEq/L which shows that the patient is taking her medication and it is in at a maintenance treatment safe range ( Reference this )

General Statement:

Caregivers): Mother and Maternal Grandmother. The mother’s boyfriend also lives in the home.

Hospitalizations: The patient Is a voluntary readmit to this hospital. The mother states that the patient has had numerous other voluntary IP hospitalizations in the past. The patient was just admitted as an IP at another hospital four weeks before this current episode.

Medication trials: Lithium 150mg, Lithium 300mg, Effexor XR 75 mg,LaMICtal 100 mg, BusPIRone 15 mg,Visearil 25 mg, Venlafaxine XR 75 mg, Lamicttal 200 mg

Psychotherapy or Previous Psychiatric Diagnosis: Bipolar Depression Disorder Current Manic with Psychotic Features, Autism, Borderline Personality Disorder, Post-traumatic Stress Disorder (PTSD) Chronic.

Substance Current Use and History: The patient denies any drug, smoking/vaping, or alcohol use at this time.

Family Psychiatric/Substance Use History: The mother, her primary support person, has post-traumatic Stress Disorder (PTSD), Autism Spectrum Disorder (ASD), the father has Bipolar with AVH, Alcohol Abuse, and has no contact with his daughter, The maternal grandmother has Post-traumatic Stress Disorder (PTSD).

Psychosocial History: The patient was born in Cleveland, Ohio, and now resides in Canton, Ohio. The patient has no siblings and lives with her mother, her primary support person, the mother has post-traumatic Stress Disorder (PTSD), Autism Spectrum Disorder (ASD), the father: Bipolar with AVH, Alcohol Abuse, and has no contact with his daughter, maternal grandmother has Post-traumatic Stress Disorder (PTSD), and the patient also lives the mother’s boyfriend as well. The patient is 15 years old with no children and is not in a relationship at this time. The patient has no military history or work history but is a full-time student in the 10th grade; her financial means of support comes from her mother. The patient states she likes listening to music, singing, drawing, and journaling. The patient has no issues with the courts or legal system, and no prior arrests. The patient has a history of sexual victimization by her maternal grandmother’s boyfriend. The abuse was reported and he was sentenced to 50 years to life. The patient also has no documented history of assaults and threats toward healthcare staff or others, even though she states homicidal thoughts but to no one in particular.Medical History: The patient has been diagnosed with Type 2 Diabetes, Asthma, Obesity ( BMI, 36.7), GERD, a History of seizures, and Psyudosieizures

• Current Medications: Lithium 300mg PO BID, Lithium 150mg PO QHS Daily, Effexor XR 75 mg PO QAM Daily, LaMICtal 200 mg PO BID, BusPIRone 15 mg PO BID, Venlafaxine XR 75 mg PO Daily, Melatonin 10 mg QHS PRN, Albuterol MDI (90 mcg/inh) 2 puffs Q4h PRN, Metformin 500mg PO QAM Daily.
• Allergies: Clonidine (seizures), Tylenol (Nausea), Tape (Rash), Mangoes (Nausea)
• Reproductive Hx: The patient states that her menstrual cycle started at the age of 13 years old. Her cycle is regular, but the bleeding is heavy for a few days. The patient’s last cycle started on 11/3/2023. The patient denies ever being in a relationship or ever having a boyfriend. The patient denies ever being pregnant or having any children. The mother placed PR on birth control at the age of 13 years old.
• Diagnostic results: The patient\’s test results show no evidence of drug, Alcohol use or signs or symptoms of any underlying infection that could be causing delirium or psychosis at this time.

IT NEEDS INFO MORE HERE

Assessment:

Mental Status Examination: The patient is A&O to person, place, time, and location. Her attention is appropriate and engaged. The patient appears disheveled hair is uncombed with poor hygiene and has a body odor. Her behavior is cooperative, with good eye contact, and appears relaxed, the patient is interacting on the unit with staff and is intrusive and attention-seeking at times but has very little interaction with her peers. The patient psychomotor activity is appropriate at this time, the patient’s speech is coherent, and she is soft-spoken, her mood is depressed and her affect on her mood is congruent. PR’s thought processes are logical and organized, with her thought content being realistic organized, and linear. The patient states that she is seeing and hearing things at this time but does not want to talk about it. The patient’s insight is limited, and her judgment is impaired at this time.

You must have at least three differentials with supporting evidence. Explain what rules each differential in or out and justify your primary diagnosis selection. Include pertinent positives and pertinent negatives for the specific patient case.

Also included in this section is the reflection. Reflect on this case and discuss whether or not you ( I) agree with your preceptor’s assessment and diagnostic impression of the patient and why or why not. What did you learn from this case? What would you do differently?

Also include in your reflection a discussion related to legal/ethical considerations (demonstrating critical thinking beyond confidentiality and consent for treatment!), social determinates of health, health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).

Objective:

3 Differential Diagnoses:

Reflections : Bipolar Depression Disorder Current Manic with Psychotic Features,

Case Formulation and Treatment Plan: