Reference no: EM133730539

Question:

P. D is a 54 -year- male with current diagnoses of bipolar who came into the clinic for a follow up appointment. He had his initial appointment on 3/12/2023 and this was a follow up. As per report from pt stating

He reported difficulty with managing stress and anxiety and difficulty with trusting people around him. He is alert and oriented x3 to person, place and time. He denied having suicidal and homicidal ideation. Pt denied having any hallucinations. He has normal speech and was cooperative. He denied using assistive device during ambulation. His affect is full. His thought process was appropriate, or goal directed. His memory remains intact. His insight and judgment to his mental illness remain fair. He endorsed having history of substance abuse stating, "I continue to drink alcohol - beer, and smoke PCP." He stated that he started drinking alcohol when he was young, while PCP was when he was 32 years old. Pt denied having family history of substance abuse. He endorsed allergic reaction to med - stating "Lisinopril, Tylenol causing throat and tongue swollen and Alive causing hives." He denied having family history of mental illness. Pt denied having family history of mental illness. He stated that he has associate degree. He reports he recently started a new job and is working to save some money so that he can leave the transitional program into his own apartment. He endorsed having been incarcerated for long time ago for domestic violence and denied having any pending court case at this time.

Pt was placed on the following medication: Lithium 300 mg 1 tablet at bedtime po x30 days Pt was educated on the benefits and risk of medications, probable side effects and interaction to report, or call 911 for ER, alternative treatment and was encouraged to take medication as prescribed.