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Subjective:

CC (chief complaint): “ I feel sadness, lack of motivation and guilt. It’s causing me so much anxiety and I don’t know how to deal with it anymore”

HPI: Patient is a 39-year-old male seen for medication management and group therapy for diagnosis of bipolar disorder. Patient has recently ended a long-term relationship and reports feeling emotionally unstable. Reports frequent mood swings with sleep disturbances, staying awake for more than 24hrs and not requiring sleep. Reports low appetite. He endorses feelings of guilt when he has anger outbursts but further explains he feels unable to control his actions at the moment. He agrees that his extreme mood swings have cause his relationships to fail. He reports history of suicide attempts with an intent to overdose on medications with alcohol in his early 20’s, leading to inpatient hospitalizations. He has a history of substance use/abuse since 2017 with his longest sobriety being 6-7 months in 2019. He reports he drinks alcohol once or twice each week, usually on the weekends. A usual amount of alcohol for him consists of a pint of whiskey. Often, he drinks until he blacks out. Reports one alcohol induce seizure.

Smokes tobacco since the age of 19 years-old. He denies other class of substance use. He remembers always suffering with feelings of depression and inability to focus due to hyperactivity, “ I was always running around getting into trouble”. In addition, he has needed little sleep since childhood……….. Continue