Care Across The Lifespan I essay paper

Care Across The Lifespan I

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Case

G.C 17-year-old Female

Medications(Active)

· OXcarbazepine 150 mg tablet

· buPROPion HCL XL 150 mg 24 hr tablet, extended release

· traZODone 50 mg tablet

Problems(All Active)

· Social phobia (disorder)

· Attention deficit hyperactivity disorder, combined type (disorder)

· Insomnia (disorder)Care Across The Lifespan I

· Generalized anxiety disorder (disorder)

· Severe mood disorder with psychotic features (disorder)

· Posttraumatic stress disorder (disorder)

History(Summary)

· PMHxCare Across The Lifespan I

· Comments: Heart murmur as baby

· PSHx

· Comments: No surgical history

· FHx

· Comments: Mother (living)- GAD, Bipolar disorder, depression Father (living)-unknown Maternal grandmother- (living) Bipolar Disorder

· SHx

· Tobacco: Never smoker

· Alcohol: Do not drinkCare Across The Lifespan I

· Drug Abuse: Illicit drug use – “I smoke four days a week.”

· Safety: Wear seatbelts

· Sexual Activity: Sexually activeCare Across The Lifespan I

· Birth Gender: Female

· OB & Preg Hx

· Ob History: Age of menses: 14

· Hospitalizations / Procedures

· No hospitalizations / procedures have been documented for this patient

· Long Term Care FacilityCare Across The Lifespan I

· No Long Term Care Facilities have been documented for this patient

· Hospice

· No hospices have been documented for this patient

· Implantable Devices

· No implantable devices have been documented for this patientCare Across The Lifespan I

New Psychiatric Admission

CC

Individual is alert and oriented x 3. She is calm and cooperative. She is accompanied by mother and sister. Mother reports that individual has anxiety and difficulty focusing. “I have mood swings. Sometimes my highs are too high and my lows are too low.” Individual reports that she does not sleep. “I can go to sleep but falling asleep is hard.” Individual rates life 7/10, with 10 being total happiness. Individua denies SI/HI. Her last suicidal thoughts were eight months ago. Individual has a diagnosis of Bipolar disorder and Generalized Anxiety Disorder. Individual reports that she has been on Adderall, Venlafaxine ER 75 mg daily, oxcarbazepine 150 mg twice daily and fluoxetine 10 mg daily. Individual reports that she sees shadow in the corner of the room. She hears voices at times. “They start getting louder in my ear. Sometimes, it’s hard to differentiate between intrusive thoughts or voices.” Individual reports that she has these thoughts or visions when she is down. Individual reports that she only eats once every two days. Individual reports that she has panic attacks.Care Across The Lifespan I

HPI

Individual reports hospital inpatient visit on 2022. “I really couldn’t get out of my low. It was getting dangerous because I couldn’t get out of it. I would say anxiety and mood swings started my seventh grade summer.” Individual reports verbal, emotional, sexual, and physical trauma from ages 5-9.

PMHx

· Comments: Heart murmur as baby

PSHx

· Comments: No surgical historyCare Across The Lifespan I

FHx

· Comments: Mother (living)- GAD, Bipolar disorder, depression Father (living)-unknown Maternal grandmother- (living) Bipolar Disorder

Soc Hx

· Tobacco: Never smoker

· Alcohol: Do not drinkCare Across The Lifespan I

· Drug Abuse: Illicit drug use – “I smoke four days a week.”

· Safety: Wear seatbelts

· Sexual Activity: Sexually active

· Birth Gender: Female

Ob Preg Hx

· Ob History: Age of menses:14Care Across The Lifespan I

Hospitalizations

Implantable Devices

· No implantable devices has been documented for this patient

ROS

Psychiatric: (+)change in mood, (+)depression, (-)sadness interfering with function, (+)anxiety, (+)nervousness, (+)sleep disturbance, (-)suicidal ideation, (+)hopelessness, (+)worthlessness, (-)delusions, (+)hallucinations

Medications

·Care Across The Lifespan I

OXcarbazepine 150 mg tablet, Take one tab twice daily

·

buPROPion HCL XL 150 mg 24 hr tablet, extended release, Take one tab daily

·

traZODone 50 mg tablet, Take one tab nightly

Allergies

No known allergies

Mental/Functional

GAD-7- 17, PHQ-9- 20, MDQ- (+)

Vitals

29 Aug 2022 – 10:55 AM – recorded by KIMBERLY NATSON

BP:

144.0 / 100.0

HR:

87.0 bpm

Temp:

97.8 °FCare Across The Lifespan I

Ht/Lt:

5′ 8″

Wt:

190 lbs 0 oz

BMI:

28.89

Comments: pain- 0/10

Assessment

Social phobia (disorder) (F40.11/300.23) Social phobia, generalized modified 29 Aug, 2022

Attention deficit hyperactivity disorder, combined type (disorder) (F90.2/314.01) Attention-deficit hyperactivity disorder, combined type modified 29 Aug, 2022Care Across The Lifespan I

Insomnia (disorder) (G47.00/780.52) Insomnia, unspecified modified 29 Aug, 2022

Generalized anxiety disorder (disorder) (F41.1/300.02) Generalized anxiety disorder modified 29 Aug, 2022

Severe mood disorder with psychotic features (disorder) (F31.5/296.54) Bipolar disorder, current episode depressed, severe, with psychotic features modified 29 Aug, 2022

Posttraumatic stress disorder (disorder) (F43.12/309.81) Post-traumatic stress disorder, chronic modified 29 Aug, 2022

Plan

Start bupropion 150 XL daily, start oxcarbazepine 150 mg twice daily, start trazadone 50 mg nightly. Monitor for and report any side effects. Call 911 or visit hospital in case of emergency. Follow up in 4 weeks. Individual and mother verbalize understanding of treatment plan.

Goals

“I want to be better.”Care Across The Lifespan I