Wk9Assgn2ANyanwuE(6635).pdf - Week Nine Psychiatric...

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Week Nine: Psychiatric EvaluationElizabeth AnyanwuCollege of Nursing-PMHNP, Walden UniversityNRNP 6635: Psychopathology and Diagnostic ReasoningDr. LeonardoJuly 30, 2021
NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation TemplatePATIENT NAME: K.LAGE: 20 yr.GENDER: femaleMarital: Single CHIEF COMPLAINT: Patient presents with Psychiatric Evaluation and hearing voicesHISTORY OF PRESENT ILLNESS:K.L is a 20 yr. old Hispanic female presents with hx of bipolar disorder and cannabis use disorder who presented here voluntarily by mother. On interview, the patient was labile and impulsive and was not able to answer most of the questions relevantly and she abruptly left the interview. Given her aggressive and unpredictable behaviors, she needed IM meds (Benadryl 50mg IM x1, Ativan 2mg IM x1, Haldol 10mg IM x1)Per mother, the patient is acutely manic, hasn’t being able to sleep (insomnia, appetite “is not normal”, and patient need total of 4 psych hospitalization in the past month and a half (x2 at xyz hospital and x2 xyz hospital) The patient is on SSI, currently homeless (will get housing in June from some government program). Mother found pt. on Friday and has been unable to redirect her at home. The patient is not taking any medication at home and believes she might be on drugs. Pt’s past medication includes risperidone, Depakote, and Zoloft and per mother, Zyprexa is not effective for patient (has done "genetic testing"). The patient has hx of alcohol use disorder and cannabis use disorder, and the mother is not sure if the patient is using methPast Psychiatric History: Per mother this is the 20thhospitalization and has been diagnosed with bipolar disorder, pt. has had previous suicide attempt ad no outpatient records at this time. Pt has also had past
psychiatric medication trials such as Zyprexa, Risperidone, Abilify, Depakote, Lithium and Geodon. Substance Current Use and History: Per mother, pt. has use Cannabis and Alcohol useFamily Psychiatric/Substance Use History: Unable to Obtain history currently. However, It is critical to take a detailed family history in order to treat an individual's illness, and this can give information for screening and identifying additional at-risk individuals who require early intervention. Obtaining a family psychiatric history is clearly beneficial clinically. (Driscoll et, al, 1990)Psychosocial History: Pt lives by herself, at this time she is homeless, waiting for housing options which will be available third week in June. Pt has SSI, unemployed, unable to obtain for legal issues, abuse, or trauma. Pt is uncooperative currentlyMedical History: Denies any medical HistoryCurrent Medications:Diphenhydramine (BENADRYL) 50 mg/mL injection.

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