Question: using this format, create another psych scenario for an 18 year old boy CC: Feeling a bit better, I just want to see my
using this format, create another psych scenario for an 18 year old boy
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CC: "Feeling a bit better, I just want to see my daughter." / Medication management
HPI: Patient is a 48-year-old male with a history of depression, homelessness, and past alcohol abuse. Seen today at the clinic for medication management. He reports improvement in mood and expresses a strong desire to reunite with his daughter in the Dominican Republic. He describes prior feelings of depression but denies any suicidal ideation, homicidal ideation, or death wish. He has no current complaints about sleep or appetite and denies auditory or visual hallucinations, delusions, or mania. The patient states, "I'm relaxed, I'm okay," and shows no signs of physical agitation.
PMH:
Medical History: Hypertension (HTN), Gastroesophageal Reflux Disease (GERD)
Psychiatric History: Depressive Disorder, NOS (F33.8), Alcohol Abuse (F10.19)
Medications:
Trazodone 50 mg qHS
Melatonin 5 mg qHS
Allergies/Intolerance:
NKA (No Known Allergies)
Family History:
Divorced, with three children. No significant psychiatric or medical history noted in the family.
Social History:
History of alcohol abuse but currently abstains, aiming to see his daughter. Previously worked as a delivery driver. Experiences homelessness and stress due to separation from daughter. Denies any current use of alcohol, tobacco, or illicit substances.
Assessment:
Alert and oriented to person, place, and time. Appears calm without signs of distress. No evidence of hallucinations or suicidal ideation. Reports feeling better with current treatment.
Treatment/Plan:
Continue Trazodone for depression; may assist with sleep as well.
Continue Melatonin as a sleep supplement.
Continue with psychology services for ongoing therapy.
Follow up in 8 weeks."
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