*The following is the patient I will present
Problem List1. Active – F3181 – Bipolar II disorder2. Active – F411 – Generalized anxiety disorder3. Active – F4312 – Post-traumatic stress disorder, chronic4. Active – F1010 – alcohol abuse history5. Active – F4310 – Post-traumatic stress disorder, unspecified
Patient HistoryPast Psychiatric History: CC: ”I’m coming back for help with psychiatric medications .”
Pt is a 39 years old female who was last seen in 2021. She stopped coming to the office and had her PCP take over managing her psychiatric medications . She has been feeling more depressed. She reports that she has a hx of depression ”my whole life.” Her upbringing was influenced by being raised by an alcoholic mother and being brought to bars and watching her mother sell herself for money. She became pregnant at a young age and her boyfriend at the time was abusive. She also had a hx of ETOH abuse, but has been sober for several years. Currently she reports sxs of racing thoughts, ”talking non-stop,” scattered thought process, tearful/emotional episodes, sleep d
isturbances, isolative, self-depreciating thoughts, hopelessness and helplessness. She has never been hospitalized psychiatrically. She denies HI but endorses passive SI. She denies any plans, means, or intent and is able to contract for safety. Pt is currently prescribed medication through her PCP: clonazepam 0.5mg BID. She has had previous trials with multiple SSRIs with only minimal effects.
Cc:’ I am between prescribers, leaving my PCP and in need of a psychiatrist’ Her PCP put her on Seroquel 50 mgs. She was prescribed Xanax and Clonazepam together by PCP ‘She had her PCP for about 3 years. Anxiety is high and also reports ‘I have PTSD.’ reports she isolates in her home. ‘I worry about everything.’ Endorsed irrational fears, obsession-type behaviors with a notebook where she writes lists. No current counselors. No psychiatric hospitalizations. Two DUIs in the last 15 years. One hospital detox with seizures. No SI or HI history. She is currently taking Cymbalta 30 mg PO BID from PCP for fibromyalgia. She was also recently prescribed Seroquel 50 mg PO QHS for sleep/mood..
Medical History: