Subjective CC: Patient said he has been feeling suicidal with plan to take rat poison. Patient said “I do not need medication; I only need therapy” HPI: Patient is a 22-year-old Caucasian male voluntarily admit to the hospital for suicidal ideation with plan. Patient has been feeling suicidal for the past 3 weeks and depressed for the past 3-4 months. Patient has history of previous psychiatric hospital but was not taking any medication. Patient states “I took Prozac before, but I got more depressed and suicidal. Since then, I refused to take any medication”. Patient endorses mood swings, constant racing thoughts, negative thoughts. Patient feels worthless and hopeless. Patient has history of being sexually, physically, and emotionally abused by biological father. Recently, patient was molested by best friend. Patient’s triggers are work, family and “other things”. Patient has a job and lives with family Substance Current Use: Patient denies used of alcohol and illegal drugs. Medical History: Obese Current Medications: None Allergies: No known allergy Reproductive Hx: Male, no children ROS General: Patient has gained 15lbs in the past 3 months Head: normocephalic, denies any history of trauma, headaches EENT: Denies eyes, ear and nose pain. Denies gum bleeding and sore throat. Cardiovascular: denies irregular heartbeat, chest pain Respiratory: Denies cough, shortness of breath Gastrointestinal: denies heartburn, nausea, denies constipation and abdominal pain, last bowel movement was yesterday, Genitourinary: denies painful urination. Patient is not sexually active Neurological: Patient denies dizziness, unsteady feet, seizure, tics. Musculoskeletal: patient denies joint paint. Hematologic: no abnormal bleeding and bruising noted Lymphatics: denies any swollen nodes Endocrinologic: denies polyuria, polydipsia and polyphagia. Skin: Denies rashes, open cut or laceration. Objective Data Diagnostic result: TSH, CMP. BMP labs would be performed to rule out any psychiatric symptoms related to medical condition. Mood Questionnaire would be provided to patient to rule out the diagnostic of Bipolar. Patient vital signs are: BP 129/78, HR 80, R 18, T 98.3, HT 5’8”, WT 234, BMI 35.6 Obese No Physical exams performed Mental Status Examination: Patient is a 22-year-old Caucasian male with some college classes. Patient is alert and oriented to name, date, time, and place. Patient is appropriately dressed for the weather. Appropriate affect. No body odor noted. Patient was able to maintain at time good eye contact but most of the time patient was looking at his hands during assessment. Speech is clear, voice is soft. Patient appears depressed and anxious. Aware of his surrounding, patient denies auditory and visual hallucination. Patient has poor insight, good recent and remote memory Differential Diagnoses Major Depressive Disorder: is a mental disorder characterized by a persistent feeling of sadness, feeling low, and/or a loss of interest in activities of daily living. (Kanter et al, 2018). Patient has been feeling depressed for the past 3-4 month resulting in suicidal ideation with plan to ingest rat poison. Bipolar Disorder: is a mental disorder characterized by period of high or mania and period of low or depression. (NIMH, 2020) Patient endorses mood swings, racing thought. Patient is feeling overwhelmed and he is seeking help.. Generalized Anxiety Disorder: is a mental health disorder characterized by excessive feeling of worry and persistent fear about a past, current, or future event. (Strohle et. al, 2018). Patient appeared anxious during assessment, poor eye contact. Patient noticed he was getting and came seeking help. Reflection If I had a chance to redo the assessment with this patient, I would have asked him his past relationship. Patient mentioned that currently, he is not in a relationship and does not have kids. Patient also has history of abuse. I would have asked patient if his past and abuses affected his current choice of being single.
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