Subjective:
CC (chief complaint): : “I have a problem in adhering to my medicines and occasionally I feel like quitting them. I don’t really think I need them. I feel like the medicine Squashes me.”
HPI: Petunia Park is a female patient who is 25 years old. She has a history of depression as well as bipolar illness, both of which she controls using medicines. During the visit today, she grouses about how much she wishes she could stop taking her medicines. The patient has expressed prior thoughts of killing themselves by taking their own life. She reports that she has a hard time falling asleep and that she regularly hears voices when she is awake. She considered her lack of sleep to be transitory and gave a rating of 15 to 21 on a Linkert scale that ranged from 0 to 28.
Substance Current Use: Reports alcohol, cigarettes, and marijuana use.
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Medical History: Denies any medical history. Reports one hospitalization due to suicide attempt.
ROS:
Objective:
Diagnostic results: no laboratory tests done
Assessment:
Mental Status Examination:
Patient is oriented x4 oriented. She is well-dressed, well-groomed and well-nourished. She cooperative as seen through her willingness to respond to questions and has clear and coherent speech. Her memory is intact. No current suicide ideation, delusions but has had auditory hallucinations and suicide attempt in the past. Her throught process is logical and judgment is intact.
Diagnostic Impression:
Bipolar disorder: The mental health condition known as bipolar disorder is characterized by extreme shifts in mood. Patients who suffer from this condition often exhibit aggressive behaviors, a propensity to get quickly sidetracked, rushed thinking, and euphoria (Vieta et al., 2018).
Depression: A low mood, along with other negative emotions such as worthlessness, despair, or guilt, is a hallmark of this mental illness. Additionally, the illness manifests itself in suicidal thoughts, and some patients even go so far as to attempt suicide (Tolentino & Schmidt, 2018).
Hypothyroidism: The main symptoms of this disorder include physiological signs, in addition to symptoms such as feelings of sadness, slow thinking processes, exhaustion, and slow movement (Duntas & Yen, 2019). In addition, there is a shortening of attention span, sleep problems, fatigue, excessive daytime sleepiness, mood disturbance, and psychotic features.
Reflections:
I would look into assessing the patient to establish if or not there are any more causes adding to her symptoms. The present diagnosis is apropriate, and it would make it easy to treat her condition.
Case Formulation and Treatment Plan:
The treatment for bipolar disorder, which is a chronic condition, focuses on relieving the symptoms that the patient is currently experiencing. It has a tremendous impact on the emotional state of a person. I will provide this patient with a prescription for a mood stabilizer of 250 milligrams, such as Depakene, to be taken two times per day. If the sympto
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