The patient is presenting with suicidal ideation with a plan and intent to jump off the bridge or self-stabs with a knife. The patient complained about his medication, Latuda is no longer working. Currently homeless with no job or income. Though calm, polite, and cooperative with organized thoughts, patient reports depression and anxiety (American Psychiatric Association, 2013).

Past psychiatric history

1- Major Depressive disorder, Recurrent Episode with psychotic features

2- Alcohol use disorder; severe

3- Bipolar I Disorder most recent episode depressed Severe

Medical history

None Reported

Substance use history

Alcohol Abuse: began drinking at age 15 and drinks 8 to 10 bottles of beer daily, yesterday was his last time he drank.

Developmental history

None Reported

Family psychiatric history

Positive for family history of mental illness on the paternal side.

Psychosocial history

The patient is unemployed and enjoys hanging out with fellow drunkards on the street with drinks, a living condition currently unstable as the patient is homeless.

History of abuse/trauma

The patient suffered abuse paternal uncle at age 12.

Review of systems

General: significant weight gain recently, positive with fatigue, but no fever or a cough.

HEENT: vision and hearing changes not reported at this time, no history of glaucoma, cataracts, diplopia, floaters, excessive tearing or photophobia, last eye exam four years ago. No ear infections, tinnitus or discharges in the ear, have no problems with smell, and taste. Denies epistaxis or nasal drainage, no any loose teeth, mouth sores or bleeding gum when brushing teeth. No difficulty with chewing or swallowing.

Neck: positive for JVD, n


 

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