Patient’s Name NNN

Age: 27 yrs old

Gender: Female
Martial: Single
Race, Ethnicity: Asian
Referral Source: Self

Source and reliability: Follow up, reliable

Chief Complaint: “Can’t sleep”

HPI: unable to sleep for almost a month, getting 1 hour of sleep per night. Feeling sad, tired and has low energy and doesn’t feel
like doing anything. Left her job almost a month ago because she felt like the bears were trying to kill her. And now she is living
with her sister because she can’t afford rent. Her sister recently had baby and the baby’s toys makes her feel scared. She did not
have toys as a child and when she grew older, she felt the toys were talking to her. These thoughts worsened when she had a car
accident 3 years ago, and had to get surgery. She tried attempting suicide twice three years ago by drinking cold medicine and
tried drowning herself but someone was able to help her both times. She has suicide thoughts at least 3-4x/ week but has no
thought
She has been drinking 2 bottle of vodka to help her sleep but she often blackouts, and had an incident where she hit her head. She
has a good relationship with her sister and mother but feels helpless. She also feels guilty that her sister is taking care of her
infant and now has to take care of her as well. She currently drinks 2 bottles of vodka to help her sleep and has blackouts from it.
She no longer has interest in doing things that she enjoys. She also reports loss of appetite and has lost 10 pounds.
Her goals are to not feel sad anymore and go out and do things. She wants to cut alcohol and be able to talk to someone

Past Medical History

Past Psychiatric History:

Past illness: Was diagnosed with depression and treated for it but stopped taking the medications when she started
feeling better because she feels like she no longer needed it. She was also diagnosed with anorexia
Compliance: She was not compliant with her antidepressant medications (does not remember the name of the
medications)
Hx of suicidality/ homicidality: She tried to attempt suicide 3 years ago by drowning herself in a bathtub and by taking
“cold” medication. She does have ideation of suicide at least 3-4x/ week but does not have a plan. She has no thoughts
of hurting others
Substance use/ abuse/ addiction
- Has been drinking 2 bottles of vodka every night since she left her job, which leads to periods of blackouts, and she
hurt her head while a blackout, but has not had a DUI
- Used “shrooms” from age 14-16
Medical Hx: Was diagnosed with anorexia as a teenager (she did not want to eat) because other students were mean to
her. She also had a car accident few years ago, which required surgery. Was also diagnosed with depression
- Allergies: cats
- Immunizations: up to date
- Medications: vitamin D
Family history:
- Father hit by a truck and passed away when she was 5 years old
- Mother: Has HF
- Sister: healthy
- Grandfather was diagnosed with depression
- Aunt committed suicide because she felt sad

Social Hx:
- Social/ Relationships: used to have friends but lost contact with them. Coworkers thought she was weird. She had one
boyfriend in the past, but he thought she was crazy and they broke up a year ago.
- Sexual hx: not sexually active
- Smoking: does not smoke
- Recreational Drugs: did shrooms between ages of 14-16
- Alcohol: started drinking when she left her job, drinks about 2 bottles of vodka
- School: wanted to go to law school but couldn’t finance it and was feeling sad
- Occupation: Worked at built a bear but left her job because the bears were trying to kill her; before that she worked as
cashier
Ros
- GI: loss of appetite and 10 pound wt loss
- Skin: no rashes, ecchymosis
 - Head: had a head injury few weeks ago
- Respiratory: no wheezing, no shortness of breath
- GU: No dysuria, hematuria

Physical Exam- done by an intern

- Vitals= T- 98F, RR- 13, BP- 127/69, O2- 98%, BMI- 17.5
- HEENT: Normocephalic, bruise on left side of the head, dry mucosa
- Cardiovascular: Normal S1 and S2, no murmurs, no JVD
- Lungs: Clear to auscultation bilaterally, no wheezes, no rhonchi
- Skin: no lesions, no cyanosis

Mental Status Exam:

- Appearance and attitude: disheveled, casually dressed, has glasses, cooperative through out the interview; intentions to
get better
- Orientation: awake, tired, oriented to time, place, name, and reason for visted
-
- Behavior: cooperative, slow psychomotor activity and hunched over, guarded
- Eye Contact: maintained very little eye contact
- Affect: appears depressed/ dysphoric and worried about her condition
- Mood: sad
- Speech: Able to articulate herself really well, but at slow rate and speed. She spoke softly throughout the interview,
clear and coherent
- Thought process: logical content, slow rate, monotone rhythm, soft volume,
- Thought content: suicidal ideation, self- harm, no intent to harm others, has delusional thinking, appears paranoid
- Insight: fair
- Judgement: poor
- Cognition: able to comprehend and answer to questions that were asked

Mini Mental Status Exam Score 28: no cognitive development

- Orientation: alert and oriented to person, place and time
- Concentration : was able to spell WORLD backwards
- Attention and immediate memory: able to repeat Apple, Table and Penny
- Short term memory: unable to recall the three words
- Language: able to correctly name objects,
- Repetition: able to repeat “no ifs, ands or buts”
- 3 step command: able to follow instructions
- Comprehension: able to see the instructions and follow written commands
- Sentence Writing: able to write in a straight sentence
- Copying: able to copy the diagram

Assessment:
- Major Depressive Disorder with Psychotic Features ICD-10-CM Code: F32.
- PTSD DSM-5 code 309.81, ICD-10 code F43.10
- Schizoaffective disorder DSM-5 code 295.70
- Head Trauma
- Delusional Disorder
Plan:
- Weekly appointments with psychiatrist and psychologists
- She will be started on 50mg Bupropion for 2 weeks and asked about her progression with the antidepressant, and see if
she might need sleeping medications
- CBC, electrolytes, and TSH labs would be drawn

Comparison of diagnosis:
I was able to determine my peers diagnosis of Major Depressive Disorder with Psychotic features. My peer primary symptoms
were related to depression that had episodes of psychotic features.
Biopsychosocial formulation
- Biological factors: genetics, prior episodes of depression, fell on head, car accident
- Psychological: delusional view that the toys are trying to kill her, feels guilt to burden family members and feels
hopeless about life. She has attempted suicide in the past and has thoughts about it several times a week.
 - Social: not able to have toys as a child, isolations from friends, ex-partner saying that she was going crazy, has good
relationship with sister and her mother
5 Diagnosis:
- Major Depressive Disorder with Psychotic Features ICD-10-CM Code: F32.
- PTSD DSM-5 code 309.81, ICD-10 code F43.10
- Schizoaffective disorder DSM-5 code 295.70
- Head Trauma
- Delusional Disorder