IDENTIFYING Identification was verified by stating of their name and date of birth.
INFORMATIO
Time spent for evaluation: 0900am-0957am
N
CHIEF “My other provider retired. I don’t think I’m doing so well.”
COMPLAINT
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 Screen of symptoms in the past 2 weeks:
SCREENING
RESULTS 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
Page | 1 Walden University, LLC
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