Out Patient Therapy Case Studies

PSYCHIATRY CONSULTATION

CHIEF COMPLAINT

This patient has been referred to me by her primary care physician. Patient states she has been suffering from irritability. She states feeling irritable for short periods of time. She associates these feelings to her depression.

HISTORY OF PRESENT ILLNESS

The patient is a 56 year old female who has recently lost her job and has been financially struggling. She has isolated herself from friends and family members. She claims to be close to her older sister but they have not spoken for the last month due to the patients’ recent behaviors. She denied illicit drug abuse she reports no legal problems and no medical problems. Patient hasn’t been feeling depressed but finds it difficult to be around anybody. She denies having any

Patient admits to taking paroxetine (Paxil) in the past for her depression but has not been taking any anti-depressants as of recent. Patient said she stop taking the medication when she felt better and did not feel she had any further use for it. FAMILY HISTORY

Patient reports both parents having substance abuse issues but she is uncertain about any other mental health condition.

PHYSICAL EXAMINATION

VITALS: Temperature 98.3 degrees. Pulse 82. Respirations 16. Blood pressure 120/74.

HEART: Regular rhythm. No murmurs.

LUNGES: Clear.

MENTAL STATUS EXAMINATION

Patient has an average female build. She displays good hygiene, no visible lesions or skin rashes. Patient does not appear to be under any physical distress. A good range of emotions displayed. Depression is apparent. No current suicidal ideation plans. Speech and language functions are adequate. Patient is alert and compliant. Patient reports no hallucinations.

MEDICAL DECISION MAKING AND OTHER DIAGNOSIS

Axis I

Bipolar 2 disorder, Hypomania and depression

Axis II

Differed

Axis III

None

Axis