COMPREHENSIVE PSYCHIATRIC EVALUATION AND PATIENT CASE DOCUMENTATION

Case Study
J. W. is a 40-year-old female Caucasian American admitted due to suicidal ideation with the plan to hang herself. The patient complained of having days without sleep.
Past psychiatric history: Anxiety, PTSD, depression. COMPREHENSIVE PSYCHIATRIC EVALUATION AND PATIENT CASE DOCUMENTATION

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Medical history: seizure
Hospitalization history: the patient had multiple hospitalizations for opioid detox.
Medication trial: Seroquel, trazodone, Remeron, lithium
Allergies: no known drug allergies.
Physical examination: BP:135/87, HR:89, Resp:20, O2:98%, Temp.: 97.8 °F
Family Psychiatric/Substance Use History: Father has depression and bipolar. The patient has used cannabis and cocaine.
Social history: The patient is married and lives with her husband. She is unemployed; she has two girls who live with her mother.
During her mental status examination, the patient was cooperative with the examiner. She is casually groomed and dressed appropriately. There is no evidence of any abnormal motor activity. Her speech is clear, coherent, and normal in volume and tone. Her thought process is goal-directed and logical. There is no evidence of looseness of association or flight of ideas. Her mood was irritable, and her affect is appropriate to her mood. She was angry during the interview. She denies visual hallucinations. There is no evidence of any delusional thinking. She denies any current suicidal or homicidal ideation. Cognitively, she is alert and oriented. Her recent and remote memory is intact. Her concentration is poor. Her insight is poor. Her judgment is poor.

COMPREHENSIVE PSYCHIATRIC EVALUATION AND PATIENT CASE DOCUMENTATION