At my first 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.

1. Medication
   a. Patient states that she has an adequate supply of medication of Seroquel and Lamictal
2. Housing
   a. Patient states that she is continuing to live with her parents until she is able to move to
   New York City to live with her boyfriend.
3. Substance Use Counselor
   a. Patient should meet with a peer to discuss her feelings about her process and thoughts
   about her goal of care before her discharge is complete.
   b. Patient was counseled about medication and mental health treatment compliance.
   Patient was also given supportive peer group resources. Patient wanted resources that
   also focused on spiritual and religious advancements. Writer was able to provide the
   patient with these resources as well.
   c. Counseled about substance use treatment options and list of regab/detox centers made
   available to the patient.
4. Collateral
   a. Provider spoke with mother to involve them in the discharge planning, Mother had agreed
   to the plan of action.
5. Safety Plan
   a. Safety plan for the patient was discussed and completed. Patient stated that she
   struggles from being triggered easily by her environment. Patient states that she has a
   hard time when her brothers smoke marijuana and when she fights with her father.
   Therefore the patient states that she recognizes the benefit to moving out of her parent’s
   home.
   b. Patient’s psychologist was contacted and an appointment was scheduled for tomorrow.
6. Mobile Crisis Referral
   a. QHC Mobile Crisis referral will also be made for additional supportive care
7. Transportation
   a. Patient is not able to be picked up by family members because they are all at work.
   b. Patient was provided a metrocard as arranged by the social work team.

Dr. Saint Martin helped guide me on how to present the case in a clear and concise manner. He asked me questions that indirectly applied to my case, which helped to broaden my scope of knowledge on this case. He gave me positive critiques on how to better refine my history and physical and how to present in better. I really appreciated listening to my other classmates presentations and felt like I learned a tremendous amount on this rotation!