Assessing and Diagnosing Patients with Mood Disorders History of Present Illness (HPI): C.W. is a 57-year-old male who presents to the facility with hallucinations.

Assessing and Diagnosing Patients with Mood Disorders

History of Present Illness (HPI): C.W. is a 57-year-old male who presents to the facility with hallucinations. He is escorted to the facility by a  nurse who volunteers at the shelter where C.W. currently stays. The nurse highlights that according to C.W.’s behavior, she suspects he is hallucinating; therefore, she sees a need for a psychiatric evaluation. The nurse reports that for the past two months since C.W. moved into the shelter, he has been telling other individuals in the shelter that he is a celebrity who is well-known globally. He believes that his famous concerts are on youtube and Google, but the nurse has not found any details about his fame on the internet. C.W. reports he sleeps for less than three hours every night. The nurse states that C.W. has not been given any medications to manage his hallucinations. C.W. has, however, undergone a few counseling sessions conducted by a therapist who volunteers at the shelter. There has not been any significant change in his hallucinations. Is your assignment devastating you ? 

Past Psychiatric History: C.W. was first diagnosed with a mental health condition at the age of 19 years. He currently lives in a shelter where a volunteer nurse monitors him. He has been hospitalized eight times in an inpatient psychiatric hospital; his last psychiatric hospitalization was eight months ago. C.W. was hospitalized once for detox 15 years ago. He has a history of an intentional drug overdose at the age of 22 years. His previous psychotropic medications include lithium, aripiprazole (akathisia), quetiapine, haloperidol (dystonia), Depakote (gastric upset), and risperidone (hyperprolactinemia). Lithium was very effective, while quetiapine did not give a fair trial. C.W. lost his medical records during the move from his apartment to the shelter and did not recall his previous diagnosis.

Substance Use History: C.W. reports that he takes 3 to 6 drinks of alcohol when playing music in the club. He does not use illicit drugs.

Family Psychiatric/Substance Use History: C.W. is not sure of family substance use and psychiatric history. He, however, recalls that he has the same behavioral traits as his aunt, who was on treatment for a mental health condition whose name he doesn’t remember.

Social History: C.W. was born and raised in Peru, Indiana. He previously lived in an apartment in Los Angeles. He lost his apartment in Los Angeles and moved to MacArthur Park for a year. He is currently living in a shelter. He also lost his job, where he worked part-time at a Home Depot. He holds a master’s degree in music theory from Stanford. He is divorced and does not have any children. He has a sister, although they are estranged. His parents are deceased, and he has no brother. He enjoys playing and listening to music. He is currently unemployed after losing his part-time job at home depot. He underwent emotional turmoil after losing his job and house.

Past Medical History (PMH): C.W. has a history of mental health conditions from 19 years, dystonia, akathisia, gastric upset, intentional drug overdose at 22 years, and hyperprolactinemia. C.W.’s immunization status is up to date. He received the Moderna vaccine for covid 19 on 9/17/2021.

Current Medications: Risperidone 2mg Nocte

Allergies: No known drug allergy. No known food allergy. Bee stings.

Reproductive history: Homosexual.

ROS:

General: Denies chills, fever, headache, day sweats, fatigue, daytime sleepiness, weight loss, or weight gain.

HEENT/Neck: Denies difficulty swallowing and rhinorrhea. Denies vision, oral, nasal, hearing and dental problems.

Skin: Denies rashes and itching.

Cardiovascular: Denies chest pains, lightheadedness, numbness in extremeties, paroxysmal nocturnal dyspnea, leg edema, slow wound healing, palpitations, arrhythmias, dyspnea, slow wound healing, or orthopnea.

Respiratory: Denies cough, choking when swallowing, shortness of breath, holding breath during sleep, difficulty breathing, wheezing, or sputum production.

Gastrointestinal: Denies indigestion, vomiting, heartburn, nausea, choking during sleep, loss of appetite, diarrhoea, acid reflux, constipation, abdominal pain, or difficulty swallowing.

Genitourinary: Denies urinary incontinence, painful urination, decreased stream, frequent urination, dribbling, and blood in the urine.

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