Criteria

Clinical Notes

Informed Consent

Patient was alert, oriented x3 and provided verbal consent to participate in the assessment.

Subjective

Verify Patient

Name: DB

DOB: 50-year-old African American female

Minor: No

Accompanied by: Patient was unaccompanied

Demographic: N/A

Gender Identifier Note: Female

CC: “I have been feeling stable and I'm taking all my medications"

HPI: DB is a 50-year-old African American female presenting for a mental health assessment. She reports taking all of her medications and states that her mood is stable. She reports sleeping and appetite are ok. She is currently attending a methadone program 3 days per week and reports taking 47 mg of methadone daily. DB was alert and oriented x3 during assessment, had proper eye contact, and denied any SI/HI or auditory hallucinations.

Pertinent history in record and from patient: Patient has a past diagnosis of schizoaffective disorder, bipolar type.

During assessment: The patient reports taking all of her medications, sleeping and appetite are okay, and attending a methadone program 3 days per week.

Patient reports taking 47 mg of methadone daily, denies any SI/HI or auditory hallucinations, and states her mood is stable

SI/ HI/ AV: Patient denies any suicidal or homicidal ideation, auditory or visual hallucinations.

Allergies: No allergies reported

Past Medical History: No medical history reported

Medical history: Denies any past medical issues.

Past Psychiatric History: Patient has been previously diagnosed with schizoaffective disorder bipolar type. She reports previous medication trials and has no history of violence to self or others.

Previous psychiatric diagnoses: schizoaffective disorder, bipolar type. Patient describes stable mood.

Previous medication trials: Patient reports taking 47 mg of methadone daily.

Safety concerns

History of Violence to self: none reported

History of Violence to others: none reported

Auditory Hallucinations: Patient denies any auditory hallucinations.

Visual Hallucinations: Patient denies any visual hallucinations.

Mental health treatment history

History of outpatient treatment: Patient reports attending a methadone program 3 days per week and taking 47 mg of methadone daily.

Previous psychiatric hospitalizations: No prior psychiatric hospitalizations reported.

Prior substance abuse treatment: Patient is attending a methadone program 3 days per week.

Trauma history: None reported

Substance Use: Patient reports using methadone daily and denies any other substance use.

Client report taking 47 mg of methadone daily.

Current Medications: 47 MG of methadone

Past Psych Med Trials: None reported

Family Medical History: Not mentioned

Family Psychiatric History:

Substance use: No substance use reported

Suicides-none

Psychiatric diagnoses/hospitalization-none

Developmental diagnoses-none

Social History:

Occupational History: None reported

Military service History: Denies previous military history.

Education history: No education history reported

Developmental History: None reported

Legal History: None reported

Spiritual/Cultural Considerations: none reported.

ROS:

Constitutional: No report of fever or weight loss.

Eyes: Eye contact was appropriate during assessment.

ENT: No report of hearing loss, tinnitus, or vertigo.

Cardiac: No report of chest pain or dyspnea.

Respiratory: No report of cough or wheezing.

GI: No report of nausea, vomiting, or abdominal pain.

GU: No report of dysuria or hematuria.

Musculoskeletal: No report of joint pain or stiffness.

Skin: No report of rash or lesions.

Neurologic: No report of weakness, numbness, or dizziness.

Hematologic: No report of bleeding or easy bruising.

Allergy: No report of allergies.

Reproductive: No report of menstrual irregularities.

Objective

Vital Signs: Stable

Assessment

DSM5 Diagnosis: with ICD-10 codes

Dx: Schizoaffective disorder bipolar type

Dx: Substance Use Disorder, Moderate

The patient meets criteria for schizoaffective disorder bipolar type as per the DSM-5. This disorder is characterized by a period of a major mood episode, either manic or depressive, that occurs with psychotic symptoms. The patient reported having a stable mood, taking all of her medications, and attending a program 3 days per week and methadone clinic. This is indicative of a stable mood disorder. According to the DSM-5, schizoaffective disorder bipolar type is diagnosed when the patient has a period of illness that consists of a major mood episode (either manic or depressive) concurrent with the active-phase symptoms of a schizophrenia spectrum disorder (Noel & Jackson, 2020).

Plan

(Note some items may only be applicable in the inpatient environment)

Inpatient

Psychiatric: bipolar as per DSM-5 criteria

Estimated stay: 4 days

Safety Risk/Plan: Patient is found to be at low risk for violence to self or others and denied any SI/HI or auditory hallucinations.

Pharmacologic interventions:

The patient should continue her current dosage of 47 MG of methadone daily and should be evaluated for additional medications to help manage her schizoaffective disorder bipolar type. Possible medication interventions include mood stabilizers, antipsychotics, and antidepressants. Mood stabilizers such as lithium, valproic acid, and carbamazepine can help to stabilize mood and reduce manic and depressive episodes. Antipsychotics such as risperidone and olanzapine can be used to reduce psychotic symptoms (Martinotti et al., 2022). Antidepressants such as fluoxetine and sertraline can be used to help manage depressive symptoms. In the case of the patient, she should be evaluated for the need for additional medications to help manage her schizoaffective disorder bipolar type.

Referrals:

Patient should be referred to a psychiatrist for further management and monitoring of her schizoaffective disorder bipolar type.

Follow-up: Patient should follow up with the psychiatrist in 1-2 weeks.

Time spent in psychotherapy: Patient should attend weekly psychotherapy sessions

Visit lasted: The visit lasted 45 minutes