The patient has seasonal allergies and she reports that she smoked in her 20’s. She had a change in her job and now works as an assistant at an Artisan Bread Bakery. She had to take this job to help with finances. She could be behind on bills. She possibly took a pay cut.…
G.S. is a very pleasant 83 year old white female admitted to the unit on 10/29/15 for congestive heart failure and shortness of breath. This is her second time being admitted within a week of discharge for the same diagnosis. G.S. is a widow who lives along at home. She has never smoked and does not drink alcohol. She is, however, a little on the obese side.…
Her depression and anxiety were rated as severe. At an office visit on 1/20/16, she stated she was having headaches 2-3 times per week and migraines every other week.…
He is not taking any medication and currently practicing conservative management due to financial problems. The patient is not working. He is an immigrant and married to the locals The patient is alert, conscious and tacypnic. He…
When confronted about admitting being suicidal and taking medication to this clinician, patient stated "I just thought I might get to go to back to Highpoint if I said that, they have some good information up there." The patient presents with minimal eye contact during the assessment and story has change a few time. The patient reports he does not have a place to go. Patient reports having a history of suicide ideation, the last one being in 2015, where he was placed at HPR, when he reports cutting himself and a history of bipolar. The patient currently has multiple laceration on both arms.…
The victim has been diagnosed with severe depression, suicidal ideation, and borderline personality disorder. Mr. Powell told the reporter three years while looking for a job, a man picked him up with another man. The two men took the victim to a Louisiana hotel and did stuff to him for a week and half. Law enforcement was contacted but was limited because they could never find the men. The victim also told the reporter at the age of 6 a man working on his father home molested him; there wasn't any specific information given.…
This week’s discussion question is about GF, a 41-year old woman who arrives for her first visit at the clinic. She reports that she has been feeling sad and depressed, with crying spells, trouble sleeping, increased appetite, impaired concentration, and fatigue. She has experienced depression in the past but was able to overcome the symptoms without medication. On physical examination, she appears to be poorly groomed and with minimal facial expressions. She is slow to respond to questions.…
Client is a 54 year old African American male who presents with mood swings, hearing voices and seeing things that does not exist. Client says he has been diagnosed with Schizophrenia and Bipolar I Disorder. Client says he recently saw his deceased grandmother at the foot of his bed point her finger and shaking her head to him. Client says he does not have a psychiatrist; however, he is prescribed Haldol. Client is seeking assistance with Region 10 Community Service Board.…
This is 67 year old white male. Patient is here to establish as a new patient and to have a general physical exam. Patient has 48 year pack history, quit 5 years ago. Patiet deneis use of alcohol or illicit drugs. Patient denies chest pain, N/V/ D, or fever.…
_____ (One) new _____ (patient) for followup. Evaluation of Left Side Pain. Patient _____ (actually) went to the ER yesterday, and was evaluated for back and abdominal pain. Initially thought she might have a kidney stone.…
The patient seems to be of a kind and considerate nature, which only makes her fears and paranoia worse. She appears to be making her paranoia worse by concerning over fictitious threats to another's…
The patient presented to the ED with an attempted suicide by overdose. Per documentation the patient was found in her car in a Randleman Wal-Mart parking lot, not breathing and with no pulse. Per Documentation EMS reports patient was seen at High Point Regional Hospital for overdose earlier this week. At the time of the assessment the patient was found asleep with her husband by her side.…
He denies feeling depressed. Patient does not appear to be exhibiting signs of agitation, aggression, or responding to internal stimuli. At the time of the assessment the patient reports vaguely remembering the events today due "blacking out". The patient states, " the only thing I really remember is the argument with my mom, then I got mad and blackout. " The patient reports walking outside and speaking with his dad about the matter, however during his conversation his sister said something he didn't like and assaulted her.…
Systemic Lupus Erythematosus Systemic Lupus Erythematosus, commonly known as SLE or Lupus is said to be a disease of the immune system called autoimmune diseases where ones immune system attacks the body with the production of antibodies. The attack causes damage and swelling to the tissues of the body. Inflammation caused by lupus can be very detrimental to major organs such as the lungs, heart, kidneys, brain and nervous system all of which are very important for the proper function of the body (Mayo Clinic Staff, 2014). Lupus affects certain racial subgroups more than others. Three times more, African Americans, Asians, and Native Americans are frequently affected by lupus than compared to whites.…
The patient is a 48 year old female who presented to the ED via LEO under full IVC by DAYMARK. The patient reports a non-compliance with her medications and experiencing auditory hallucinations. The patient denies suicidal ideations and homicidal ideations. The patient reports depressive symptoms as:guilt, fatigue, tearfulness, anhedonia, and isolation. During the time of the assessment the patient was alert and calm.…