Order Psychosocial History Assignment

Order Psychosocial History Assignment
Psychosocial History: K.G. is a 17-year-old African-American male who was born and raised in Houston by both parents. He is an only child. He is an 11th-grade student who goes to school and misses several days without going to school. He lives in a community that is very diverse in population and culture. K.G. refuses to attend church with his family and hangs around peers in his neighborhood. He enjoys biking and working out in the gym. He is planning to quit school after 12 grade to start his own business.
Substance Current Use: Smokes cigarettes during manic episodes to calm him. Denies use of unwanted substances or alcohol.
Medical History:
· Current Medications: No current medications.
· Allergies: No drug or food allergies.
· Reproductive Hx: Not married, never had a girlfriend, and has no children.
Order Psychosocial History Assignment
· GENERAL: K.G. had no cough, fever, or weight gain.
· HEENT: K.G. had no hearing or vision loss. No eye, ear, or throat infection. No neck pain was reported.
· SKIN: No skin infections, bruises, or lesions.
· CARDIOVASCULAR: No unusual heart rhythm, palpitation, or edema on lower extremities.
· RESPIRATORY: No abnormal breathing, congestion, wheezing, coughing, sputum
production, or respiratory infections.
· GASTROINTESTINAL: No digestive or bowel problems and no blood m stool reported.
· GENITOURINARY: Urine change in urine color and no pain involved with urinating.
· NEUROLOGICAL: No reported seizures, dizziness, headaches, and no numbness, or tingling. K.G. had good body balance.
· MUSCULOSKELETAL: No fractures, broken bones, or muscle pain.
· HEMATOLOGIC: No anemia, bleeding disorder, or blood infections.
· LYMPHATICS: No enlargement of lymph nodes.
· ENDOCRINOLOGIC: K.G. has no night sweats, polydipsia, or polyuria.
Vital signs: BPl 10/65, T 97.8. RR20, 02, 99%
Diagnostic results: Baseline labs CBC, CMP, TSH, T3, and T4, lipid panel, hepatic function, B12 level, and UA. (All within normal).
Order Psychosocial History Assignment
Mental Status Examination: The patient is a 17-year-old African-American male who looked his stated age. He was alert and oriented, casually dressed, and poorly groomed. He had minimal eye contact. His thought process was clear and coherent, talked rapidly and loudly. No looseness of association. No evidence of delusional thoughts, hallucinations, or disorganized behaviors. He appeared slightly distracted during the evaluation. His affect was dull and his mood depressed. He denied any thoughts or intent to hurt himself or others. His memory was intact but had little insight into the disease process.
Diagnostic Impression:
Main diagnosis, Bipolar I Disorder: Per the DSM-5 criteria, to diagnose an individual with this disorder, the manic episode must be preceded by a hypomanic or depressive episode. The manic episode must last for at least seven days characterized by persistently elevated mood, and goal­ directed activity. During the period of the elevated mood disturbance, the individual experiences increased energy level or activity. The individual presents any three of the following, grandiosity, decreased need for sleep, talkative, increased goal-gated activities, flight of ideas, distractibility, or engaging in risky activities (Bobo, 2017). The mood disturbance is severe enough to cause a disturbance in the individual’s social, academic, or occupational functioning. The disturbance must not be associated with the use of substances, an underlying medical condition, or another mental disorder (Bobo, 2017). K.G. meets the full criteria for this diagnosis as he had three manic episodes within the past year lasting up to seven days each, he is hyper, talkative, aggressive during manic episodes, and engages in risky activities such as fighting. Also, his manic episodes are followed by episodes of depression with K.G. reporting feeling depressed, low energy, increased isolation, lack of motivation, decreased concentration, and loss of appetite. This makes Bipolar I disorder the primary diagnosis for my patient.

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