Patient is a 68 y/o married Hispanic female presenting for psychiatric evaluation and medication management. Patient see with husband. She reports she has been anxious since her early twenties, but since her 36 year old daughter died last year (3/18/17). Patient reports feelings of depression, sadness, lack of focus, tearfulness, hopelessness, helplessness, guilt, anxiety with panic attacks, worthlessness, irritability, forgetfulness, anhedonia, not wanting to leave house, poor sleep, passive suicide ideations, stating “I want to be with my daughter and God.” Convincingly denies plan and intent, stating “I am Catholic and I wouldn’t go to heaven if I took my pills and died.” Denies HI and auditory hallucinations, reports visual hallucinations of daughter. Husband offers collateral information, “she’s even afraid to die and wakes up disoriented at 830 pm and thinks its 830 am.”
Denies history of homicide attempts/ideations. No weapons or firearms at home.
PCP has been prescribing Xanax 1 mg TID ‘for years’ with good effect. Xanax was recently switched to clonazepam 2 mg BID – causing sedation. NJ PMP aware verified.
PCP also prescribed Effexor 75 mg HS 2 months ago and increased dose to 150 mg with poor effect.
Has over the phone grief counseling with insurance company with good effect, attends a support group and is looking forward to beginning a depression program through her insurance company.
Substance Use & Abuse History: (Include substance abuse treatment)
Denies ETOH abuse – ‘just a small drink once a week.’ Denies other history of other illicit drug usage, or abuse of prescription medications.
Allergies & Adverse Drug Reactions: NKA
Family Psychiatric History:. Denies family history of psych treatment or suicides.
Other Relevant Psychosocial History: (developmental, social, educational, vocational, trauma, etc.)
Lives with Husband who works 2pm – 10 pm+ Married 40 years.
Grieving after loss of daughter (36 y/o living in supportive housing – Dx hydrocephalus)
Employment: Retired 10 years ago. Worked with computers.
Trauma hx: Death of daughter
Emigration to US from Cuba at age 15. Speaks English fluently now.
Denies child abuse/neglect, rapes, domestic violence.
Relevant Legal Issues: No history of arrests or current legal issues reported.
Medical History: (Significant illness and treatment, surgery, head trauma, exposure to toxins, etc.)
Reports ‘stomach issues,” HTN, high cholesterol, COPD, psoriasis. Denies DM and hypothyroidism. Reports cholecystectomy & hysterectomy. Followed by DR XXXXX. Last seen 2 weeks ago. Medically stable. Denies other history of major medical hospitalizations, surgeries, seizures, or concussions reported.
Takes iron infusions, nexum, Losartan, Topral xl, liptor, Advair.
Mental Status Examination:
Appearance and Behavior: Well groomed, overweight, cooperative with interviewer
Affect: sad, tearful
Speech: Normal rate, soft spoken, normal production
Process: Goal directed
Content: Relevant to
Delusions: Denies current paranoid delusions
Hallucinations: Denies current auditory hallucinations. Reports seeing deceased daughter.
Suicidal/Violent Ideation, Impulse, : Denies current suicidal/homicidal ideation or plans
Orientation: Alert, awake, oriented x 3
Memory: Recent Intact Remote: Intact
Abstraction: Age appropriate.
Judgment, Insight: Insight – good – good
Patient is proactive in seeking treatment and recognizes the need for medication to stabilize her mood and thoughts
Consumer’s Expressed Interests, Preferences, Strengths and Goals: (Related to behavioral health services, valued roles, and quality of life)
Strengths: proactive, husband
Goals: “To have a life, volunteer.”
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Clinical Impressions: (Rationale for diagnosis and recommendations for services) ?
DSM-5 Diagnosis: ?
Psychiatric Medications: ?
Drug: Dose/Schedule: Number/Refill: Fact Sheet Given Other
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