Patient is a 33 y/o married Caucasian female presenting for psychiatric evaluation and possible medication management.

Presenting Problems/Issues:

Patient is a 33 y/o married Caucasian female presenting for psychiatric evaluation and possible medication management. Patient reports an extensive dug and alcohol abuse history, is currently on methodone maintenance for the last 5 years. The patient reports irritability, impulsivity, increased depressing, not wanting to get out of med, no interest in formally pleasurable activities, anxiety, insomnia, fatigue, tearfulness, inability to concentrate. Symptoms have gotten worse since she returned to her husband after a 6 month separation. Denies thoughts of death or suicide. Reports mood swings and irritability – recently throw a remote and broke a $700 TV.

Psychiatric History/ History of Psychiatric Medication and Response: (Dates of episodes, hospitalizations, precipitants, symptoms, treatment and response, periods of remission. Include substance abuse, suicidal/assaultive behavior) (List medications, dosage, side effects, response where known.)

No history of psychiatric hospitalizations reported. Denies history of major suicide/homicide attempts, reports overusing drugs to the point ‘no return.’ Has taken Lexapro (some success for awhile), Wellbutrin (too strong), Prozac w/ Risperdal causing galactorrhea. Sees a counselor at the methodone clinic, a personal Addiction counselor and is in marriage counseling. Reports husband has a gun at home, but keeps the bullets separately – he is licensed. Denies history of auditory/visual hallucinations. Denies history of delusional thinking. Reports history of manic symptoms, reports mood swings, irritability, impulsivity.

Substance Use & Abuse History: (Include substance abuse treatment)

Long drug and alchohol hx. Used drugs beginning at age 9 – invited to share with mother and step dad. Currently sober. Goes to AA. Sober x 3 years, on Methadone x 5 years. Current dose 30 mg, from a clinic in Kearny. Had been on methadone 1 other time before. Drug of choice was heroin, then ETOH and cocaine. Has been to NA, but doesn’t feel safe there.

Denies current illicit drug usage, or abuse of prescription medications.

Reports tobacco use – 1 pk cigarettes daily. Not wanting to stop now, has tried to stop in the past with gum/patch.

Allergies & Adverse Drug Reactions: NKDA, NKFA, seasonal allergies

Family Psychiatric History: Reports Depression, anxiety, bipolar, drug addition, Alzheimer’s on mother side Father is bipolar and a crack addict – unmedicated. Denies other family history of psych treatment or suicides.

Other Relevant Psychosocial History: (developmental, social, educational, vocational, trauma, etc.)

Lives with husband and his parents – causing great strife. Keeps an apartment – but won’t let her husband move in there. Husband is controlling – wants her to work but only as a waitress. Has no children. In marriage counseling, married since 4/14. Left him in October and recently returned.

Education hx: hs grad, associates degree and is a certified drug counselor

Employed currently unemployed. HX of waitressing in the past, telemarketing, house cleaning

Trauma hx: Reports hx of domestic violence – had several restraining orders against prior boyfriend- who kidnapped the patient and her against her will. She describes him as a psychopath. Denies current domestic violence. Reports witnessing her father through the mother down the stairs and broke the patient’s arm. Father and mother and step father are crack addicts.

Relevant Legal Issues: Went to jail 30 days. X 2. Discharged to a substance abuse plan x 2. Has a pending court date for falling asleep at the wheel recently, denies DWI.

Medical History: (Significant illness and treatment, surgery, head trauma, exposure to toxins, etc.)

No history of major medical hospitalizations, seizures, or concussions reported.

No medical medications. Takes 30 mg of Methadone – wants to get off of it.

Ca in cervix and had a portion removed and can not have children.

Reports PCOS.

Last physical exam date:__2 weeks ago __________ Results: enlarged heart

Last laboratory date: _______2 weeks ago_______ Results: WNL

Primary Physician: ______Dr XXXXX

Practice Location: ________XXXXX NJ

Mental Status Examination:                                                                                                  

            Appearance and Behavior: Well groomed, thin, cooperative with interviewer

              Affect: anxious, cooperative

              Mood: “sad, anxious”

              Speech: Normal rate, volume, production


                Process: Goal directed

                Content: Relevant to conversation

        Delusions: Denies paranoid delusions


   Hallucinations: Denies auditory/visual hallucinations.

Suicidal/Violent Ideation, Impulse, Intent: Denies suicidal/homicidal ideation or plans


                      Orientation: Alert, awake, oriented x 3

   Memory:   Recent   Intact     Remote:   Intact

                          Abstraction: Age appropriate.

              Judgment, Insight: Insight – fair. Judgment – fair

Patient is proactive in seeking treatment and recognizes the need for medication and therapy to manage her mood and anxiety. However has a tendency to blame other for her life choices.

Differential diagnosis includes. GAD, MDD

Consumer’s Expressed Interests, Preferences, Strengths and Goals: (Related to behavioral health services, valued roles, and quality of life)

Strengths: motivated

Goals: “be able to get my life back – not depressed”

Student APN’s Name:

Other information you might want?

Clinical Impressions: (Rationale for diagnosis and recommendations for services) ?

DSM-5 Diagnosis:?


Labs: ?

Psychiatric Medications: ?

Drug:                                              Dose/Schedule:                             Number/Refill:                                           Fact Sheet Given     Other

Rationale for each recommendation: ?

?RE: to you comment. the items with question mark ? are the questions to be answered


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