At my site evaluation I presented the following case:

28 y/o female unemployed, college student, past psychiatric history of bipolar disorder (I), alcohol
abuse, cocaine abuse, brought in by ambulance, activated by self after arguing with father today. Patient
states that she had a fight with her father and she felt “uncontrollably violent and upset.” Patient states
that she did not want to be “upset to the point where I would hurt my father or hurt myself so I called the
ambulance.” Patient states that she took “over 100 pills two years ago because I was so upset.” Writer
spoke to the patient’s mother who states that her husband was upset with the patient because she “did
not come home for a few days and when she does that she is normally doing drugs.” The patient
endorses cocaine and alcohol use on Saturday and Sunday. Mother states that her husband (the patient’s
biological father) called the patient on Saturday and told her to “stay where you are and do not return to
the house.” Mother states that the patient returned home today and “my husband was very upset.” Mother
states that her father does not want the patient home because of her chronic drug use. Mother states ” we
have tried our best with her and sent her to rehab, paying for her college tuition and when she does drugs
she doesn’t go to school. We are trying everything for her but it is not working.” Mother does not have any
safety concerns about the patient but states “I don’t think she can come home to live with us right now.”
Upon assessment in CPEP, the patient was casually groomed in street clothing, she is crying but
cooperative, speech is normal in rate, tone and behavior, psychomotor activity normal. Her thought
process is linear and logical and goal oriented. Patient states that she has a psychologist but that she had
missed her last appointment. No odd or delusional or paranoid behavior. Patient denies suicidal or
homicidal ideation, intent or plan Patient denies auditory and visual hallucinations. Mood is anxious and
depressed. Affect is constricted and congruent to mood. Patient states that she has been prescribed
Seroquel 75 mg and Lamictal 150 mg but states that she is compliant.

Dr. Saint Martin worked with me to discuss the plan of care. He asked me questions that were indirectly related to my case to help broaden my scope of knowledge. He assisted me in learning about the medications and the side effects. He also expressed interest in learning about the plan of care offered by the providers and how he felt towards that plan of care. He helped me in the way that I presented the case. Helping me consolidate what was important as I presented the case to him.