Comprehensive Psychiatric Evaluation Note

Client Initial: Mrs. A. J. Age: 56 years, Race: Caucasian,

Diagnosis:

1.Mood Disorder

2. Anxiety Disorder

2. Trauma and Stress-Related Disorder

Chief Complaints

Client shares that she has had anxiety and depression since she was 10yo. She has been prescribed meds over the years doesn't like taking them long term. Client has a prescription for Xanax but has not taken in 3 months. Client hasn't been able to get herself "back into a groove." Client shares that it has been over the past year that it has become harder to get motivated. Normally, can eat right, exercise and meditate. Client shares a long history of trauma and loss. Comes from a small town in Maryland where many of her childhood friends and family have overdosed or committed suicide. Her sister has multiple mental health issues and has stolen her family’s life savings. Client states that she left home when she was eighteen and feels the only reason she survived is because she left.

History of Present Illness

Does client require assistance via a qualified interpreter?: No

If yes, was the client provided information on how to access an interpreter?: Not Applicable Verified the client's identification and location People present at visit Client Relationship status Married Personal pronouns she/her/hers

Gender identity: Female

History of present illness checklist

Symptom How Long?, How Often?, Intensity, Aggravating Factors, Alleviating Factors,

Sleep not sleeping well, can stay awake past10 pm, sleep 3-4 hours daily and always have difficulty sleeping.

Appetite hasn't eaten yet today at 3 pm, lack of appetite

Concentration okay Mood unpredictable great, really bad its internal Irritability 100% around her period Energy unpredictable

HPI Narrative (if you would prefer you can write as narrative instead here):

Patient states that she started experiencing increase in loss of appetite, inability to sleep for over a week.

Current Safety Status

Reviewed with client that sessions are not recorded, and confidentiality is maintained unless a patient is a danger to oneself, others or is court ordered.

Does the client require a safety plan at this time? No

Self-harm? Denied

Suicidal intention? Denied

Violent thoughts and/or impulses? Denied

Homicidal thoughts and/or impulses? Denied

Does the client feel safe at home? Yes

Does the client have access to weapons? Yes, locked up Past or present risk factors?

Exposure to Domestic Violence Substance Use lack of appetite, younger cocaine use

Past Medical History

Past inpatient hospitalizations, partial/residential programs, outpatient programs or provider, had sepsis at 3 yrs, hit by a drunk driver in 2011, torn aorta several hospitalizations related to this

Current inpatient hospitalizations, partial/residential programs, outpatient programs or providers: No

Past medications and dosages/efficacy/side effects allergic to sulfa and Secor took Klonopin briefly, Lexapro briefly

Current medication dosages/efficacy/side effects and client's feelings about medications Xanax prn and skin medication

Is medication being taken as prescribed? Yes

Current providers to collaborate with for continuity of care (email [email protected] to request release for current providers) no

Client provided verbal authorization to collaborate with the providers listed above.

Medical Assessment

Significant past medical history: Torn aorta

Any concerns related to brain health or functioning? Trouble with memory, short term

Current non-psychiatric medications? skin meds

Allergies? Sulfa

Any Current Medical Conditions or Concerns? No

Client identified trauma: Physical, Mental, Emotional, Bullying, Intimate Partner Violence Traumatic Grief, Accident,

Does the client experience any of the following?

Intrusive Memories/Thoughts, Reliving the Event, Nightmares, Avoidance, Memory Loss, Hopelessness, Detachment

Lack of Interest in Previously Enjoyed Activities: Numbness, Outbursts, Guilt/Shame, Difficulty Concentrating, Hyper Vigilance.

STUDENT NOTE

Client reports meeting all appropriate developmental milestones on time. Developmental milestones ahead of developmental milestones, very bright intellectually

Family History: brother: opioid addict, sister: mental health issues, mom major anxiety and depression, aunt, and grandmother mental health.

Social History

Who does the client identify as their "family" (biological or chosen support system) mom dad brother

How Does the Client Describe Their Childhood? when she was 7yrs. old her sister started having serious mental health issues, stopped eating. client never felt safe as sister was difficult to manage. No history of adoption in the family, client lives with her husband who is a military/ marine. Client has many college credits in musical, business, and finance, but no degree. Past employment includes mortgage company, bartender but not currently working.

Does the Client Have any Past or Current Legal Involvement? Incarceration? History of/or Current Restraining Order Involvement? No

Support System: Peers, Friends, Colleagues, Community, husband, family, few very close friends from childhood

What Does the Client Identify as their Hobbies, Interests, or Activities? Had 2 dogs, 1 died recently. Training the dogs, cooking, exercise.

SUBSTANCE USE

Caffeine; maybe 1 x a week and Alcohol; every night 2 glasses wine

Age of First Use? 16 years

Does the Client Express Concern About Any of the Above Substances? No concern

Does the Client's Family/Job/Community Express Concerns About the Above Substances: No Have the Substances had an Impact on Family/Job/Community? No

Review of Systems (ROS)

Mental Status Exam

Appearance: Within Normal Limits

Attitude: Within Normal Limits

Behavior: Within Normal Limits

Psychomotor (involuntary movements, agitation, tics, tardive dyskinesia or chorea): Within Normal Limits

Mood: Notable depressed

Affect: Notable labile, tearful

Speech: Within Normal Limits

Thought process: Within Normal Limits

Thought content: Within Normal Limits

Perceptions (hallucinations or illusions): Within Normal Limits

Cognitive (alertness, attention, memory, executive function): Within Normal Limits

Orientation (alert and oriented to person, place, date and time): Within Normal Limits

Insight: Within Normal Limits good insight

Judgment: Within Normal Limits

Knowledge and fund of information appropriate to educational background: Within Normal Limits

ASSESSMENT

Assessment Notes: Were you able to gather all the assessment data in the above intake questions? Fully Completed

Based on session what is your overall clinical picture of the client and their needs? Client has a long history of trauma, depression, and anxiety. She would benefit from a combination of talk therapy and medication. Multiple losses, mental illness in family of origin, financial crisis in family

PLAN:

Clinician suggested: Getting a notebook, writing down concerns and issues to discuss, nightly sleep meditation, deep breathing, and a thirty minute walk every day.

Have You Scheduled a Follow Up Session? If Yes, Date? Yes, 9/29/22 at 3p

REFERRAL OR CONSULTS

Does the client need a psychiatric consult for medication? Yes, I think this client would do well with an SSRI. has tried Klonopin and Lexapro in the past didn’t like them.

ADMINISTRATION

Client was given a way to reach provider between sessions (contact number, email or instructed to contact clinic)

Clinical Diagnosis Formulation that Supports Diagnosis (rendered at time of diagnosis): Client is traumatized by the sheer volume of people she knows that have either overdosed or committed suicide. She has suffered from anxiety and depression from age seven when her sisters mental health began to show serious signs in the house

Diagnoses

Post-traumatic stress disorder, chronic [ F43.12] Depression, unspecified [ F32.A ]Generalized anxiety disorder [ F41.1 ]

Plan

Treatment Notes

Initial Treatment Plan

Treatment Goals: Treatment Goals/Hopes Identified by Client

I attest that I have collaborated with the client listed above to identify their goals for the initial treatment session. The client is in agreement with this treatment goal(s) and has verbally given consent for this treatment plan.