NR 548 Week 6 Psychiatric Interview Documentation Assignment...

Name: Shandrisha Lawson Past Psychiatric History - Includes all previous mental health psychotherapy and medication management. Be as descriptive as possible. Include type of provider, name if provided, year(s) of treatment, types of services received, history of trauma, self-harm or harm to others. Bipolar/ depression – diagnosed 20-22 years ago. Receives treatment from VA with current medication of lithium and Wellbutrin. Reports 20 years ago while being a physician in the military he was under stress and lost some patients which caused him to have a break. Hx of childhood verbal and physical abuse from mother. ADD with no official diagnosis that was presented by his provider in 1998 Medical History (PMHx) – Includes active medical problems (currently getting managed) and past medical problems (no longer needing any intervention), hospitalizations, and surgeries. Depending on the CC, more info may be needed. Hypothyroidism with current tx of Synthroid, dosage is unknown Family History (Fam Hx) - History includes but is not limited to illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first-degree relatives should be included. Include parents, grandparents (if information was provided), siblings, and children. Include grandchildren if pertinent. Mother bipolar or schizophrenia(several psych hospitalization), breast cancer (deceased) Father- diabetes Brother- depression Daughter- depression Name: Shandrisha Lawson ☐Pain on Inspiration Click or tap here enter text. ☐Other: Click or tap here to to enter text. ☐Sensation Changes enter text. ☐Snoring : Click or tap here to enter Choose an item. text. ☐Speech Deficits Click or tap ☐Other: here to enter text. Click or tap here to enter text. ☐Other: Click or tap here to enter text. Hematology/Lymphatics GI GU Endocrine If patient denies all symptoms for this If patient denies all symptoms If patient denies all symptoms for If patient denies all symptoms for system, check here: ☒ for this system, check here: ☒ this system, check here: ☐ this system, check here: ☒ ☐Anemia Click or tap here to enter ☐Nausea/Vomiting Click or tap here to ☐Urgency Click or tap here to text. enter text. enter text. ☐Increased appetite Click or ☐Dysphasia Click or tap here to ☐Polyuria Click or tap here to tap here to enter text. ☐Other Click or tap here to enter enter text. enter text. ☐Increased thirst Click or tap text. ☐Diarrhea Click or tap here to enter ☐Nocturia Click or tap here to here to enter text. text. enter text. ☒ Thyroid disorder ☐Appetite Change Click or tap here to ☐Incontinence Click or tap hypothyroidism enter text. here to enter text. ☐Heat/cold intolerance Click or ☐Heartburn Click or tap here to enter ☐Other: Click or tap here to tap here to enter text. text. enter text. ☐Excessive sweating Click or ☐Abdominal Pain Click or tap here to tap here to enter text. enter text. ☐Diabetes Click or tap here to Click or tap here to enter text. enter text. ☒Other: Click or tap here to enter text. ☐Other Click or tap here to enter text. O: Objective