Comprehensive Psychiatric Evaluation and Patient Case Presentation

Comprehensive Psychiatric Evaluation and Patient Case Presentation;

 

CHIEF COMPLAINT: “I got caught into it.”

 

H.P. is a 40 y/o African American female who was transferred to ED via police due to bizarre and erratic behavior with auditory hallucinations. Patient attempted to stick people with a pen at a convenience store. Patient has had numerous hospitalizations in different hospitals but her last admission in this hospital was 3 years ago. Patient didn’t follow up and non-compliance with her medications. During interview, patient noted laughing and smiling inappropriately. Thoughts are racing and scattered. Patient disorganized, delusional, paranoid and suspicious of others. Feels watched and followed. Lacks energy and motivation. Patient has not been sleeping well at night. She reported she has been hearing voices telling her to kill herself. Denied visual hallucination and suicidal/homicidal ideations. No drug/food allergies reported. UDS positive for marijuana and ETOH <10. Patient presents as a danger to self and others.

 

PAST PSYCHIATRIC HISTORY: Multiple hospitalizations, non-compliance to treatment. No past suicidal or homicidal reported.

 

PAST MEDICAL HISTORY: Severe anemia, the cause not clear.

FAMILY HISTORY: The patient has a family history of bipolar and depression, but no detail given.

 

SOCIAL HISTORY: The patient is not married, but she has 5 children, all are grown up and they all live with the other family members. The patient has no job. She receives monthly social security check. Patient is currently homeless. Patient is positive for marijuana. Denied alcohol or illicit drug using.

 

DIFFERENTIAL DIAGNOSIS

 

1. Schizophrenia, unspecified

2. Marijuana use disorder

3. Non-compliance with medications

 

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