Subjective:CC (chief complaint): “I feel sad most of the time; the next minute, I’m overly excited. I think I’m going crazy. Little things irritate me.”HPI: P.O is a 34-year-old patient who came to the unit for his follow-up visit after being diagnosed with bipolar disorder 6 months ago. She complains that she feels sad most of the time,followed by episodes of being overly excited. She reports being easily irritated and agitated. She also found it difficult to concentrate on tasks. She reports feeling depressed for over a week and could not go to work. Additionally, she states that her depressed episodes are usually followed bymanic episodes of feeling overly elated and overjoyed, full of energy, easily distracted, self-important, and great new ideas about her art projects. She also reports there was a time she went about 3 days without sleep and had to be admitted to the hospital. Moreover, the client reports needing pleasure in casual sex by random guys, which has affected her relationship with her boyfriend. Her sister noted that the client once threatened her with a knife when they had a confrontation. She also threatened to harm herself if her boyfriend refused to forgive her for cheating. Substance Current Use: P.O. reports that she usually smokes cigarettes when drinking. She reports recreational alcohol use and drinks about 4 bottles in a sitting, mostly over the weekend. She also drinks a glass of wine after evening meals. According to her sister, who accompanied her to the hospital, the client has blacked out twice after heavy drinking. She reports drinking a lot when stressed up. However, she denies marijuana, cocaine, illicit drug use, or prescription pain medication addiction. She also denies a history of arrests
Social History: The patient reports living alone but sometimes visits her boyfriend. She lived
with her mother until 3 years ago because she feared living by herself due to her suicidal
thoughts. She also reported hearing voices in the dark and could not sleep alone. However, she
visited a counselor who helped her with these symptoms. However, the symptoms have since
returned.
Medical History:
The client reports that she recently underwent minor laparoscopy surgery for a biopsy following
an H-pylori infection that caused hematemesis and blood in the stool. She was also hospitalized
when she went three days without sleeping and hurt herself by cutting her wrist.
Current Medications: Lamotrigine and Quetiapine
Allergies: She denies any seasonal medication, food, or known drug allergies.
Reproductive Hx: She is a sexually active heterosexual and was recently tested positive
for a sexually transmitted infection, which was treated in the outpatient department. She
denies any previous pregnancies or childbirth and reports consistent condom use since the
STI diagnosis. Additionally, she reports multiple sexual partners during her manic
episodes.
ROS:
General: The patient reports gaining 2 lbs. within a month. She denies fever, chill, or
night sweats. However, she reports fatigue and weakness
HEENT: she denies head trauma or injuries. Eyes: she denies double vision, blurred
vision, yellow sclerae, or vision loss. Ears, Nose, and Throat: she denies ear pain, hearing
loss, or ear drainage; runny nose, sneezing, or congestion; and sore throat
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