Patient J.B. is a 33-year-old Caucasian female who presents for initial psychiatric evaluation with consent obtained

The Patient info:
Subjective: Patient J.B. is a 33-year-old Caucasian female who presents for initial psychiatric evaluation with consent obtained. She is currently in an inpatient treatment facility for addiction. She reported that she wants to “continue out-patient treatment because she is a recovering addict”. She noted that she abuses crack cocaine and has been in the treatment facility since August 25, 2023, and is expected to be discharged on October 4th, 2023. She reported that she also abuses alcohol and she “drinks to blackout”. She stated that she tends to be restless, can’t stay still and always looking for something to do. She reported that she makes bad choices whenever she is under the influence of drugs. The client stated that she has been diagnosed with PTSD, Anxiety, Epilepsy, and Asthma. She noted that she grew up with her mother and 6 siblings (four brothers and two sisters). She stated that her father wasn’t in the picture and was also an addict. She reported that she was sexually abused by her cousin as a child and has experienced domestic violence from her last partner who she claimed kicked her in the stomach and injured her spleen. She completed high school and proceeded to cosmetology school. She has three kids from three different men with the last child being 9 months old. She was never married. she stated that she was on a pre-trial release for 2nd-degree assault 4 months ago for breaking the nose of her partner’s female friend. she noted that she has an anger management problem.
Objective:
General Appearance:
Neat & clean., Poor Hygiene. Tired. Disheveled. Inappropriate. Other:
Eye contact: Normal. Avoidant. Intense. Other
Psychomotor Activity: Normal, retarded or rigidity/repetitive movements
Orientation: Person. Place. Time. Situation.
Attention: Intact. Distracted. Confused. Inattentive. Other:

BEHAVIOR: Cooperative. Resistant. Tired. Paranoid. Anxious. Guarded. Defensive. Agitated, Impulsive. Withdrawn. Stereotyped. Hyperactive. Other:
SPEECH: Normal. Tangential. Pressured. Slowed. Rambling. Mute. Soft. Loud. Other:
MOOD: Euthymic. Euphoric. Dysthymic. Angry. Depressed. Irritable. Anxious. Hostile. Neutral. Elated. Apathetic
AFFECT: Appropriate. Manic. Blunted. Labile. Full. Constricted. Flat. Reactive. Restricted. Incongruent. Exaggerated.
THOUGHT PROCESS: Linear. Goal-Directed. Illogical. Disorganized. Poverty of Thought.
THOUGHT CONTENT: Intact. Flight of Ideas. Tangential. Blocking. Circumstantial. Loose.

PERCEPTIONS: Good. Fair. Poor
INSIGHT: Good. Fair. Poor.
JUDGMENT: Good. Fair. Poor.
COGNITION: Intact, Fair. Poor.
Language. WNL. Abnormal
MEMORY: None. Immediate. Recent. Remote.

C-SSRS (CURRENT)
1. WISH TO BE DEAD:
have you wished you were dead or wish you could go to sleep and not wake up? No
if yes, describe:
2. NON-SPECIFIC ACTIVE SUICIDAL THOUGHTS:
have you had any thoughts of killing yourself? No
if yes, describe:
3. ACTIVE SUICIDAL IDEATIONS WITH ANY METHODS (NOT PLAN) WITHOUT INTENT TO ACT
have you been thinking about how you might do this? No
if yes, describe:
4. ACTIVE SUICIDAL IDEATIONS WITH SOME INTENTS TO ACT, WITHOUT SPECIFIC PLAN
have you had these thoughts and had some intentions of acting on them? No
if yes, describe:
5.ACTIVE SUICIDAL IDEATIONS WITH SPECIFIC PLAN AND INTENT
have you start to work out or worked out the details of how to kill yourself? No
if yes, describe:
C-SSRS (LIFETIME)
1. WISH TO BE DEAD:
have you wished you were dead or wish you could go to sleep and not wake up? NO
if yes, describe:
2. NON-SPECIFIC ACTIVE SUICIDAL THOUGHTS: In the past, not now.
have you had any thoughts of killing yourself? NO
if yes, describe:
3. ACTIVE SUICIDAL IDEATIONS WITH ANY METHODS (NOT PLAN) WITHOUT INTENT TO ACT
have you been thinking about how you might do this? NO
if yes, describe:
4. ACTIVE SUICIDAL IDEATIONS WITH SOME INTENTS TO ACT, WITHOUT SPECIFIC PLAN.
have you had these thoughts and had some intentions of acting on them? NO
if yes, describe:
5.ACTIVE SUICIDAL IDEATIONS WITH SPECIFIC PLAN AND INTENT: NO
have you start to work out or worked out the details of how to kill yourself? NO
if yes, describe:
PROTECTIVE FACTORS:
RISK ASSESSMENT: Low
SAFETY PLAN RECOMMENDATIONS: TO CALL 911 IF FEELING SUICIDAL
Psychosis: Y/N No
Diagnosis Formulation:
Score on Administered Screening Tool: PHQ score 16/27,
Assessment:
The client is a 33-year-old Caucasian female seen via telehealth for initial psychiatric evaluation. She is currently in an inpatient treatment facility for substance abuse and will be discharged on the 4th of October 20123. The client stated that she wants to continue her treatment in an outpatient setting. The client abuses crack cocaine, Alcohol, and Marijuana. She noted that she “drinks to blackout” and that she makes bad decisions when under the influence of substances. She reported anxiety most of the day and also when she wakes up from sleep. She grew up with six siblings and a mother. Pt father was not in the house and he abused alcohol. Pt completed high school and cosmetology school. She reported sexual abuse by her cousin when she was a child and domestic violence from her male partners. she reported that her last partner kicked her in “the stomach and split my spleen” last year. She has three children from different men and the last child is 9 months old. She denied having flashbacks to those events but remembers them when she narrates the ordeal. She reported trouble sleeping and staying asleep and her appetite is good. she reported that she has gained some weight while in the inpatient treatment facility and attributed it partly to her meds. She is on a pre-trial release for 2nd-degree assault on another female. She noted that she has an anger management problem. Pts PHQ score is 16/27 while on anti-anxiety medication and her score on GAD is significant.
The patient will start Seroquel 150mg@ at bedtime for mood stability; she will continue Lexapro 10mg for Anxiety daily and Hydroxyzine PRN. The patient will start Topomax to reduce cravings for drugs. Pt will benefit from Psychotherapy to help build resilience and positive coping skills to manage anxiety and anger
Plan: The 90 plan is to reduce depression and anxiety symptoms
To continue substance abuse recovery.
Start psychotherapy. Call the office in 2 weeks if no appointment for psychotherapy is made.
Start with Seroquel 150mg at bedtime. Starts Lexapro 10 mg as needed. Start Topomax 25 mg daily. The patient is to report any medication S/E to the provider
Pt to send her discharge papers and lab results to the clinic
To call 911 if SI/HI/AH/VH.
Follow up in weeks.

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