CategoryItemValue Client InformationSitePrivate Practice AgeAdult (18- 64 years)

CategoryItemValue
Client InformationSitePrivate Practice
AgeAdult (18- 64 years)
GenderFemale
Visit InformationStudent Level of FunctionIndependent – Level 5
Category of CareDirect Patient Care
Practice ManagementType of visitConsultation
Diagnosis1 Mood Disorder
2 Personality Disorder
Student Notes26 years old female with past psychiatric history of Schizophrenia, PTSD, Bipolar disorder and polysubstance abuse who presents to the clinic complaining of feeling very sad and depressed. She is presenting with acute exacerbation of chronic mental illness in the setting of homelesnesss, interpersonal conflicts with partner, poor compliance with medication and substance abuse.
Tx: Depakote 500 mg BID, monitor levels
Risperdal 1 mg at bedtime
Follow up appointment in 3 weeks.