Past Psychiatric and Substance Use Treatment

Identification was verified by stating of their name and     date of birth.

Time spent for evaluation: 0900am-0957am

 

Chief Complaint

“My other provider retired. I don’t think I’m doing so     well.”

 

HPI

25 yo Russian female evaluated for psychiatric     evaluation referred from her retiring practitioner for PTSD, ADHD,     Stimulant Use Disorder, in remission. She is currently prescribed     fluoxetine 20mg po daily for PTSD, atomoxetine 80mg po daily for ADHD.
Today, client denied symptoms of depression, denied anergia, anhedonia,     amotivation, no anxiety, denied frequent worry, reports feeling     restlessness, no reported panic symptoms, no reported obsessive/compulsive     behaviors. Client denies active SI/HI ideations, plans or intent. There is     no evidence of psychosis or delusional thinking. Client denied past episodes of hypomania,     hyperactivity, erratic/excessive spending, involvement in dangerous     activities, self-inflated ego, grandiosity, or promiscuity. Client reports     increased irritability and easily frustrated, loses things easily, makes     mistakes, hard time focusing and concentrating, affecting her job. Has low     frustration tolerance, sleeping 5–6 hrs/24hrs reports nightmares of     previous rape, isolates, fearful to go outside, has missed several days of     work, appetite decreased. She has somatic concerns with GI upset and     headaches. Client denied any current     binging/purging behaviors, denied withholding food from self or engaging in     anorexic behaviors. No self-mutilation behaviors.

 

Diagnostic Screening Results

Screen of symptoms in the past 2 weeks:
PHQ 9 = 0 with symptoms rated as no difficulty in functioning
Interpretation of Total Score
Total Score Depression Severity 1-4 Minimal depression 5-9 Mild depression     10-14 Moderate depression 15-19 Moderately severe depression 20-27 Severe     depression
GAD 7 = 2 with symptoms rated as no difficulty in functioning
Interpreting the Total Score:
Total Score Interpretation ≥10 Possible diagnosis of GAD; confirm by     further evaluation 5 Mild Anxiety 10 Moderate anxiety 15 Severe     anxiety
MDQ screen negative
PCL-5 Screen 32

 

Past Psychiatric and Substance Use Treatment

· Entered mental health system when she was     age 19 after raped by a stranger during a house burglary.

· Previous Psychiatric     Hospitalizations:  denied

· Previous Detox/Residential treatments: one     for abuse of stimulants and cocaine in 2015

· Previous psychotropic medication trials:     sertraline (became suicidal), trazodone (worsened nightmares), bupropion     (became suicidal), Adderall (began abusing)

· Previous mental health diagnosis per     client/medical record: GAD, Unspecified Trauma, PTSD, Stimulant use     disorder, ADHD confirmed by school records

 

Substance Use History

Have you used/abused any of the     following (include frequency/amt/last use):

 

Substance

Y/N

Frequency/Last Use

 

Tobacco products

Y

½

 

ETOH

Y

last drink 2 weeks ago, reports drinks 1-2 times       monthly one drink socially

 

Cannabis

N

 

Cocaine

Y

last use 2015

 

Prescription stimulants

Y

last use 2015

 

Methamphetamine

N

 

Inhalants

N

 

Sedative/sleeping pills

N

 

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