Comprehensive Psychiatric Evaluation and Patient Case Presentation

Comprehensive Psychiatric Evaluation and Patient Case Presentation

Gender: female

Age: 32 years old

T- 98.4 P- 76 R 20 137/74 Ht 5’5 Wt 113lbs

CHIEF COMPLIANT: “I thought I was going to die that night.”

Hx : Patient is a Caucasian lady who was Born and raised in St Louis , MO. After high school years in East St. Louis later moved her and her sisters to California so that she can go to university where she loved to.

At the university in California, she met her husband who is a psychiatric mental health patient with diagnosis of schizophrenia. They live in St Louis, MO.

SC. She obtained her bachelor’s degree in education, no history of mental health or substance

use treatment, no family history. Her husband reported once had a crisis when he brutally killed their dog and almost Choke their neighbor to death. Jennings had been having serious concern and some fear about this bizarre behavior before she was literarily attacked by her schizophrenic husband. JENNING stated that “ I thought I was going to die that night “ neighbor called the police while I was fighting for my life. Since then, anytime I see someone who looks like him I got scared and shortness of breath, heart racing, palpitation, and I will be screaming. They thought I was crazy at my job, and they had to let me go because the day that I had this crisis many customers left and did not want to witness such. No prior psychiatric hospitalization no family history of anxiety disorder.

UDS Positive for Alcohol (25)

THC positive

Amphetamine positive

PSYCHIATRY HISTORY:

No psychiatric history reported

MEDICAL HISTORY:

No medical history reported

PSYCHIATRIC FAMILY HISTORY:

Denied psychiatric family history

ALLERGY:

No drug/food allergies reported

Major Diagnosis: Post traumatic stress disorder (PTSD)

Differential Diagnosis:

Generalized Anxiety disorder

Substance Abuse disorder

Alcohol use disorder