CC: “I started shaking about 2 months
CC: “I started shaking about 2 months ago, and I’m having serious chest pains and anxiety attacks because my brother wants me to move out. I am not using either.” The client presents to initial therapy appointment, distressed following recent discussion with brother recently diagnosed with lung cancer. Client has been living with brother over the past 6 months, and she has been grateful for the opportunity to take care of him, as extensive alcohol abuse history has interfered with their relationship previously. Client has history of multiple hospitalizations secondary to polysubstance use. Alcohol is drug of choice. Smokes 1 PPD cigarettes, denies current alcohol use, cannabis use, stimulant use or any illicit drug use. Sexually active. Client has been taking her current medication regimen since she was discharged from most recent inpatient psychiatric hospitalization 1 year ago, at which point she presented with suicidal ideation without plan or intent, along with severe alcohol intoxication. The client’s primary care provider has been refilling psychiatric medications q3 months following hospital discharge due to patient’s reticence to establish care with a new psychiatric provider. Client’s brother has given her one week to turn in mandatory disability paperwork for her own income-based housing, which must be signed by psychiatric provider as proof of disability. She will be homeless otherwise. MEDICATIONS: 25mg Benadryl OTC Melatonin 5mg HS Abilify 7.5mg HS Celexa 15mg QD Trazodone 200mg HS MEDICAL DIAGNOSES: Hyperlipidemia Hx of Atrial Fibrillation Hx of Withdrawal Seizures VITALS: HR: 102 BPM BP: 121/92 TEMP: 97.8 HT: 5’5″ WT: 155 lbs. ALLERGIES: NKDA Seasonal What symptoms should be prioritized and assessed further in this case and why? What are three priority safety concerns for this client, given medication history, vital signs, medical history and psychiatric history? What additional information would you like to have? Discuss three prioritized questions you would ask to formulate a prescriptive strategy? Would you order labs for this client? Why or why not? If so, what labs would you order? From the patient’s perspective, what is the prioritized treatment outcome? Provide rationale. Separately, discuss two different proposed medication adjustments, providing rationale for each. Rationale should outline why each med adjustment could achieve the aforementioned prioritized treatment outcome. What patient education would you incorporate in this initial psychiatric evaluation? Include education for each medication change proposed above. # 8Would you refer this patient to another specialist for follow-up care? If so, include indication and specialty, with rationale for doing so. If not, include rationale supporting no referral.
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