Wiki Can someone code this BH visit, Please!

Brenda1973

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Diagnosis: Bipolar I w/ comorbid CPTSD

Assessment and Plan:
Patient endorses symptoms of severe mood swings, with current symtpoms of anhedonia, instrusive thoughts, depressed mood, passive SI, psychomotor slowing, and increased appetite. Patient reports that these symtpoms are present on a fluctuating basis, but have been triggered particularly severely over the course of the past week in the context of a recent Sexual assault.

Patients presentation is most consistent with ongoing chronic Bipolar disorder, with acute exacerbation of CPTSD secondary to recent acute traumatic event.
 
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