Chief complaint: “I have a horrible mood swings and I get angry easily.”
HPI: Mark is a 37 years old Caucasian male with no prior psychiatric hospitalizations who presents to outpatient clinic for evaluation and treatment of symptoms of mood swings. He reports long history of mood instability beginning in his early teens and continue to worsen throughout his twenties and thirties. Mark reports irritability, agitation, raising thoughts, chronic sleep difficulties. Reports using marijuana to calm down once- twice a month, drinks alcohol 3-4 cans of beer on weekend. Denies bad dreams or nightmares, denies obsessive thoughts, denies hallucinations, and paranoia. Denies sudden weight loss, excessive sweats, hair loss, and chronic fatigue.
Psychiatric History: Mark has never been hospitalized for psychiatric illness, no history of suicide attempts, no homicide attempts, and no history of violence. However, he reports frequent thoughts of deaths when very depressed in the past three months. He has never seen a psychiatric provider prior to this visit. He has been prescribed selective serotonin reuptake inhibitors (SSRI) by his PCP in the past for treatment of depression. Mark reports that the medication did not make much difference in treating his symptoms.
Past Medical History: Mark reports childhood asthma, depression and anxiety.
Surgical History: Tonsillectomy
Family Medical History: Mother has depression, type 2 diabetes mellitus, CKD, CVA; died of kidney failure at age 75. Father- Schizophrenia, HTN, CAD; died at age 50-years.Brother has bipolar and has alcohol problems. Sister is healthy but has “very mean attitude.”
Social History: Lives with girlfriend of one year in a rental apartment. Mark works part time at a local construction company. Girlfriend works full time at a departmental store. Denies history of tobacco use.
Family History– Mark and his brother were physically and emotionally abused by father as a child. He did not recall mother stepping in to provide protection when father was abusive. Mark has a strong relationship with his cousin who is two years younger. Mark’s sister is 20 years old and lives at mother’s house along with her two years old daughter. Brother lives with his friends.
Review of Systems: 10-system ROS negative except symptoms noted in HPI.
Medications: None
Allergies: NKDA
Vital Signs: BP 110/60 HR 65bpm, T 98.9F, RR 12/min Weight 170lbs without significant recent changes.
SAE Instructions
Review the above case study and complete the SAE assignment. Please use the SAE template that is provided in blackboard to complete the assignment and follow the instructions. Remember to use appropriate APA in-text citations and reference list. SAE is due by Sunday at 11:59pm (ET).
