NAME: Karen S. L.
BIRTHDATE: 12/29/95
AGE: 26
GENDER: Female
PRIMARY CARE PHYSICIAN:
PROVIDERS:
INFORMANT(S): Client_X__ Parent___ Spouse___ Relative___
REFERRAL SOURCE: Valley Medical Arts.
REASON FOR REFERRAL: Diagnosed with Anxiety and Depression
PRESENTING PROBLEMS & HISTORY: (list of problems and brief synopsis of problems reported by client)
Client reports she recently got a dental procedure done. She states that it was a very traumatic procedure where she thought she would lose her teeth. She went to the dentist and told them she thought she would lose her teeth. The doctor told the client that she would be fine. Client stated that she felt unheard. Client explains that it was very traumatic for her, and she kept telling everyone around her that there was something wrong and no one understood her fear of losing her teeth. Her husband convinced her to get help because he was worried about her anxiety over her losing her teeth. She stated that she went to so many dentists in which procedures were done that weren’t to her liking continuing to feel unheard, causing her to have a dental phobia. client states that going through all this, she realized that she has very bad anxiety. She reported that this experience was similar to when she was in high school. She stated that when losing her virginity, she told Her then-boyfriend, who was five years older, to stop because she was scared and felt paralyzed because he wouldn’t stop. Although she loved him, she noticed he didn’t use protection and thought she might have had an STD or was pregnant. Client stated that the feeling was similar to what happened with her dentists. She explains that she can’t control her thoughts and feelings. She either wants to lay down all day or run.
Onset and Duration:
Client reports that lately, she’s been wanting to leave her husband. States she got married too young although he’s a wonderful guy, she’s never been on her own and wants to explore that. However, she’s scared to be alone. She doesn’t know if maybe she wants to leave him because of her anxiety. She mentions that she feels selfish having these thoughts.
Impact on functioning:
Recently she’s been having thoughts of wanting to run and never stopping.
RELEVANT BACKGROUND HISTORY
Mental Health: (prior mental health Tx, issues, disposition; or other Tx since last seen)
She was diagnosed with depression and anxiety.
Living Environment: (current living situation, cohabitants, marital status, custody, friends, support system):
Client is currently living with her husband and has a good relationship with him.
Developmental History:
Client reports that she was born in Mexico. She came to the United States when she was 5. Her upbringing was difficult. She witnessed so many things at a young age. one of the things she mentions is seeing her mom dragging her dad out of bars because he was too drunk. She also reports that her dad would constantly verbally abuse her.
Education/ Work History:
Client reports she is a meteorologist. Graduated with a degree in meteorology and a minor in journalism.
Social/Activities:
Client mentioned that she likes to play basketball, run, and go hiking. She goes out with her best friend to get coffee or go shopping. States that when she does go out with her friend, it’s family-oriented outings. When she attempts to go out with other friends, her mom tells her that she shouldn’t be going out because she’s married and that it will look bad.
Medical History:
Client reports that she has stomach issues but doesn’t know if the cause of her stomach issue is because of her anxiety. She mentions that she has psoriasis and gastritis.
Family Medical History:
Legal: (arrests, convictions, injunctions, litigation pending, parole/probation; or since last seen)
She denied any legal problems.
Substance Use: (personal, family history-list and describe; Alcohol use? (last use, type, frequency, amount, first time, etc.)
No substance or alcohol use. She states that she doesn’t drink because her dad is an alcoholic.
MEDICATIONS
1. None
2.
STRENGTHS/ WEAKNESSES
Strengths: Clients strengths are that she sets goals and accomplishes them. She’s also compassionate with people.
Weaknesses: Client explains that she’s too emotional and her anxiety.
ASSESSMENT OF MOOD AND PHYSICAL PROBLEM/SYMPTOMS -(Inquire specifically regarding the following clinical symptoms)
Mood: ___No Change ____Increased __X__Decreased
Sleep: ___No Change ____Increased __X__Decreased
Interest/ Pleasure: _X__No Change ____Increased ____Decreased
Motivation: _X__No Change ____Increased ____Decreased
Energy: _X__No Change ____Increased ____Decreased
Concentration: _X__No Change ____Increased ____Decreased
Memory: _X__No Change ____Increased ____Decreased
Apetite, Weight changes: ___No Change ____Increased __X__Decreased
Self Concept: _X__No Change ____Increased ____Decreased
Anxiety / Worries: ___No Change __X__Increased ____Decreased
RECENT/CURRENT SUICIDAL IDEATION
Have you had thoughts of suicide or killing yourself? NO or YES– if yes, describe: No.
History of SI, plan, or attempts? NO or YES– if yes, describe: No.
SCREENING RESULTS
PHQ-9 Score: 25
GAD7 Score: 21
MENTAL STATUS EXAM & BEHAVIORAL OBSERVATIONS
Appearance: Appears stated Age__X__ Older Appearance_____ Appropriate Attire__X__ Dishelved____ Unkempt___ Meticulous___ Unusual___ Other______________
Attitude/ Approach: Cooperative_X__ Guarded___ Withdrawn___ Noncompliant___ Defensive___ Hostile___ Uncooperative____ Provocative___ Demanding___ Indifferent___
Orientation: Fully Oriented_X__ Disoriented ____ Confused____ Disoriented to time, date, and place_____
Attention: Within Normal Limits___ Distracted_X__ Limited____ Vigilant____ Drowsy___
Mood: Within Normal Limits___ Neutral_X__ Depressed___ Euphoric___ Elevated___ Anxious___ Fearful___ Irritable___ Angry___
Affect: Within Normal Limits_X__ Broad___ Restricted___ Flat___ Inappropriate___ Labile___ Incongruent___
Immediate Memory: Intact_X__Slightly reduced____ Mildly Reduced____ Moderately Reduced____ Deficient____
Motor Activity: Unremarkable_X__ Slow____ Restless____ Agitated___ Tremors___ Rigid___
Declarative Memory: Intact___ Slightly Reduced__X__ Reduced and Deficient with detailed information___ Moderately Impaired____ Severely Impaired_____
Speech: Normal_X__ Low volume____ Articulation deficits____ Slurred___ Whispering Voice___ Echolalia____ Expressive Deficits___ Limited ___
Fund of Knowledge: Average_X_ Above Average___ Below Average___ Limited___ Deficient____
Language Skills: Good aural comprehension_X__ Decreased Verbal Fluency___ Word Finding Deficits____ Expressive Aphasia___ Grammatical Errors___
Thought Processes: Goal-Directed__X__ Tangential _____ Circumstantial_____ Flight of Ideas____ Loose Associations____ Perseveration____ Blocking____
Thought Content: Relevant to Topic__X__ Somatic focused____ Preoccupation____ Guilt_____ Religion____ Grandiosity_____ Suicidal Ideation____
Hallucinations: None_X__ Auditory____ Visual____ Tactile____ Olfactory____
Delusions Ideas: None_X__ Phobias___ Jealousy____ Somatic____ Persecution____ Control____ Religion____ Guilt____
CLINICAL AND DIAGNOSTIC IMPRESSIONS
1. Unspecified anxiety disorder,
2. Medical history: psoriasis and gastritis.
3. Psychosocial Stressors: Marital conflict, Anxiety.
4. RULE OUT diagnoses: Major depressive disorder.
TENTATIVE TREATMENT PLAN
1. Further treatment is recommended and client will be scheduled for individual psychotherapy treatment.
2. Continue to gather relevant information from client and complete clinical assessment to determine the focus of treatment.
DIAGNOSTIC EVALUATION
NAME: Adonis A. C.
BIRTHDATE: 02/02/1996
AGE: 26
GENDER: Male
PRIMARY CARE PHYSICIAN:
PROVIDERS: Practicum student
INFORMANT(S): Client_X__ Parent___ Spouse___ Relative___
REFERRAL SOURCE: Self-referred
REASON FOR REFERRAL: The client self-referred due to experiencing symptoms of depression as noted in the referral form.
PRESENTING PROBLEMS & HISTORY: (list of problems and brief synopsis of problems reported by client)
The client reported symptoms of depression which was diagnosed in 2019 and increased throughout the course of the COVID-19 pandemic.
The client reported receiving a diagnosis of ADHD in 2019 and currently uses medication for treatment.
The client reported experiencing the termination of a relationship on December 31, 2021 which had increased negative emotions and feelings of depression.
The client reported that an acquaintance passed away due to COVID-19 infection.
The client experiences an unstable relationship with his father which he reported was due to a traditional Hispanic upbringing.
Difficulty coping with major life changes including loss of employment and loss of romantic relationships.
The client reported that he recently disclosed that he was bisexual to his parents and reported that he had experienced some conflicts related to this disclosure. The client reported that his extended family did not know his sexual orientation.
Onset and Duration:
The client reported that he was diagnosed with Major Depressive Disorder and Attention-deficit/hyperactivity disorder.
He reported that his symptoms of depression had increased during the past 2 years (since start of pandemic) due to a variety of life events and changes.
Impact on functioning:
Impact on function related to depression include changes in weight (reported losing 10 pounds and gaining 5 pounds within 1 to 2 weeks), unstable sleep patterns, loss of motivation, difficulty engaging in hobbies, and problems with self-esteem.
RELEVANT BACKGROUND HISTORY
Mental Health: (prior mental health Tx, issues, disposition; or other Tx since last seen)
The client reported that in 6th grade he attended mental health services with a psychologist for one year due to behavior issues. He reported that this treatment was helpful and that he benefited from the services.
The client stated that he was diagnosed with depression in 2019 and received a one month supply of anti-depressants which he felt did not cause any significant changes.
The client reported that he was diagnosed with ADHD in 2019 and currently uses medication to treat symptoms.
Living Environment: (current living situation, cohabitants, marital status, custody, friends, support system):
The client resides with both biological mother and father and stated that his father is frequently away for work throughout each week.
He has one younger 18 year old brother and one younger 18 year old sister. He reported that his mother was his biggest support system.
Developmental History:
The client reported meeting all developmental milestones and stated that in the 6th grade he participated in mental health services for behavioral issues including anger and conflicts with parents.
Education/ Work History:
The client stated completing his bachelor’s degree in Biology in 2017.
He stated that he worked as a scribe for 2 years and was laid off due to the COVID-19 pandemic. The client verbalized negative emotions regarding being laid off.
The client reported working at a pharmacy for 1 month and stated that he quit due to conflicts with his employer.
Social/Activities:
The client reported that he enjoyed oil painting but had not been motivated to paint due to symptoms associated with depression.
During intake session client reported that a major influence was Amy Winehouse and that he had been significantly impacted by her death.
Medical History:
The client reported that in 2009 he received surgery for the removal of a benign tumor located on his spine.
He reported that he currently experiences chronic pain due to the surgery. Additionally, he expressed that he experiences low self-esteem due to surgical scars.
Family Medical History:
The client reported a history of anxiety and depression within both biological parents. He stated that his father was diagnosed with anxiety and depression and was currently being treated with medication. He stated that his mother has not received a diagnosis but also struggled with symptoms.
The client reported that his grandparents had been diagnosed with dementia. He stated that his had caused significant distress and reported that it was difficult to spend time with them .
Legal: (arrests, convictions, injunctions, litigation pending, parole/probation; or since last seen)
The client denied legal complications.
Substance Use: (personal, family history-list and describe; Alcohol use? (last use, type, frequency, amount, first time, etc.)
The client reported that he occasionally consumed alcohol. He described his alcohol use as social. Last date of consumption was 4/23/22.
The client denied use of any other substances.
MEDICATIONS
1. The client stated that he currently used medication for the treatment of ADHD.
2.
STRENGTHS/ WEAKNESSES
Strengths: The client identified his strength as being creativity.
Weaknesses: The client reported low self-confidence as a weakness.
ASSESSMENT OF MOOD AND PHYSICAL PROBLEM/SYMPTOMS -(Inquire specifically regarding the following clinical symptoms)
Mood: ___No Change ____Increased __X__Decreased
Sleep: ___No Change ____Increased __X__Decreased
Interest/ Pleasure: ___No Change ____Increased __X__Decreased
Motivation: ___No Change ____Increased __X__Decreased
Energy: ___No Change ____Increased __X__Decreased
Concentration: _X__No Change ____Increased ____Decreased
Memory: _X__No Change ____Increased ____Decreased
Apetite, Weight changes: ___No Change ____Increased __X__Decreased
Self Concept: ___No Change ____Increased __X__Decreased
Anxiety / Worries: _X__No Change ____Increased ____Decreased
RECENT/CURRENT SUICIDAL IDEATION
Have you had thoughts of suicide or killing yourself? X NO :
History of SI, plan, or attempts? X NO
SCREENING RESULTS
PHQ-9 Score:
GAD7 Score:
MENTAL STATUS EXAM & BEHAVIORAL OBSERVATIONS
Appearance: Appears stated Age____ Older Appearance_____ Appropriate Attire_X___ Dishelved____ Unkempt___ Meticulous___ Unusual___
Attitude/ Approach: Cooperative_X__ Guarded___ Withdrawn___ Noncompliant___ Defensive___ Hostile___ Uncooperative____ Provocative___
Orientation: Fully Oriented_X__ Disoriented ____ Confused____ Disoriented to time, date, and place_____
Attention: Within Normal Limits_X__ Distracted___ Limited____ Vigilant____ Drowsy___
Mood: Within Normal Limits___ Neutral___ Depressed_X__ Euphoric___ Elevated___ Anxious___ Fearful___ Irritable___ Angry___
Affect: Within Normal Limits_X__ Broad___ Restricted___ Flat___ Inappropriate___ Labile___ Incongruent___
Immediate Memory: Intact_X__Slightly reduced____ Mildly Reduced____ Moderately Reduced____ Deficient____
Motor Activity: Unremarkable_X__ Slow____ Restless____ Agitated___ Tremors___ Rigid___
Declarative Memory: Intact_X__ Slightly Reduced____ Reduced and Deficient with detailed information___ Moderately Impaired____ Severely Impaired_____
Speech: Normal___ Low volume_X___ Articulation deficits____ Slurred___ Whispering Voice___ Echolalia____ Expressive Deficits___ Limited
Fund of Knowledge: Average_X_ Above Average___ Below Average___ Limited___ Deficient____
Language Skills: Good aural comprehension_X__ Decreased Verbal Fluency___ Word Finding Deficits____ Expressive Aphasia___ Grammatical
Thought Processes: Goal-Directed__X__ Tangential _____ Circumstantial_____ Flight of Ideas____ Loose Associations____ Perseveration____
Thought Content: Relevant to Topic_X___ Somatic focused____ Preoccupation____ Guilt_____ Religion____ Grandiosity_____ Suicidal Ideation____
Hallucinations: None_X__ Auditory____ Visual____ Tactile____ Olfactory____
Delusions Ideas: None_X__ Phobias___ Jealousy____ Somatic____ Persecution____ Control____ Religion____ Guilt____
CLINICAL AND DIAGNOSTIC IMPRESSIONS
1. F32.1 Major Depressive Disorder, Moderate
F49.1 Unspecified Anxiety Disorder
2. Medical history: Removal of benign tumor in 2009 which the client stated causes chronic pain.
3. Psychosocial Stressors: Psychosocial stressors include family relationships, sexual orientation and acceptance within family, loss of relationships, and loss of employment.
4. RULE OUT diagnoses: Attention-Deficit/Hyperactivity Disorder
TENTATIVE TREATMENT PLAN
1. Further treatment is recommended, and client will be scheduled for individual psychotherapy treatment.
2. Continue to gather relevant information from client and complete clinical assessment to determine the focus of treatment.
DIAGNOSTIC EVALUATION
NAME: KARINA
AGE: 23
BIRTH DATE: 02/03/99
GENDER: Female
PRIMARY CARE PHYSICIAN:
PROVIDERS: Practicum Student
INFORMANT(S): Client X
REFERRAL SOURCE: Self-referred
REASON FOR REFERRAL:
An evaluation was requested for diagnostic determination and treatment planning, KARINA was self-referred for a diagnostic evaluation for differential diagnosing and treatment planning.
PRESENTING PROBLEMS & HISTORY:
According to KARINA, the following problems and symptoms are affecting her daily functions at home and school/work.
• Anxiety
• Stress management
• Lack of motivation
Body insecurity
KARINA stated, “I’ve been having a lot of anxiety, the last crisis I had was involving an anxiety attack and it was kind of severe”. She says she does not like the way she has been feeling. She noted, “I hyperventilate, experience hand sweating, and have chest pains.” When I experiences such symptoms, I break down and begin crying. She noted that she attempts to calm herself down. She says she used to experience these symptoms every 6 months, but now it is every 2 months. KARINA indicated constantly worrying about everything in her life. She reported overthinking plans and solutions as well as fear in making the wrong decision. She stated, “Back when I was an undergraduate I didn’t know if moving out of my house was a good idea” or “I just do not want to mess up.” She also reported not being able to relax. She mentioned, “I want to get everything done in one day.” She reported difficulties maintaining asleep. She stated waking up feeling tired and with a major headache. However, she noted that recently she has been oversleeping. She also noted experiencing problems with her memory. KARINA indicated that at times she forgets if she brushed her teeth, so she needs to redo it.
KARINA indicated she does not have a good relationship with her sister, she says that her sister makes her feel worthless. She noted she feels insecure with herself and believes what her sister tells her. KARINA has had past suicidal ideation such as questioning why she is here. She also noted she recently thought about why she is here but has never had a plan to commit suicide. She also reported a lack of motivation. She noted she used to enjoy going out to the gym before but recently it has been something she has been struggling to do. KARINA also reported an increased cravings for food and weight gain. She reported gaining a total of 20 pounds, and being hungry constantly throughout the day.
Onset and Duration: She noted she encountered her first anxiety attack when she was an undergraduate back in 2018. Per KARINA, when she was finishing up her undergraduate degree, she began worrying about her schoolwork. Karin stated she believed she was going to fail an exam and decided to go to the gym in order to cope with her thoughts. However, she stated that while in the gym she began experiencing anxiety attack symptoms including, hyperventilating, hand sweating, and chest pains. Towards the end of the intake session, Karina noted, “I believe my anxiety and low mood began earlier than that due to the relationship I have with my sister.”
Impact on functioning:
• Isolates herself
• Has difficulties concentrating
• Gained weight
• Difficulties sleeping
RELEVANT BACKGROUND HISTORY
Mental Health: KARINA reported having a counselor a couple of years ago. She stated counseling was a good experience for her. KARINA reported past suicidal ideation, she admitted to having thoughts such as, “why am I here.” KARINA denied any current suicidal or homicidal ideation.
Living Environment: She currently resides with her mother, father, and older sister in San Juan, Texas. She reported having a good relationship with her parents. However, she noted her father is frequently in and out of the home due to his occupation. Per KARINA, her parents are very religious. She stated she was not allowed to have a boyfriend. KARINA noted she had her first boyfriend when she graduated college. She reported she has been with her boyfriend for a few years now. KARINA reported she does not have a good relationship with her older sister. Per KARINA, she and her boyfriend frequently have arguments due to how her sister treats her. She noted her sister has a strong personality. She stated her sister makes her feel insecure and regularly makes fun of how she walks. Per KARINA, when she has arguments with her sister or when her sister is yelling at home, it causes her to hyperventilate.
Developmental History:
• KARINA was born in McAllen, Texas. Developmental milestones were reached at the appropriate timelines. No speech therapy or occupational therapy was reported. No history of childhood abuse. She denied any domestic violence in the home environment.
Education/ Work History: KARINA reported she completed her bachelor’s degree in psychology at UTRGV. Since graduating, she returned to a master’s program in Counseling at UTRGV. She reported having a passion in helping others and her goal was to provide the best help possible to people dealing with anxiety and depression. KARINA noted that she has online courses. She says she prefers the traditional classes because it requires her to pay attention and have more of a structure, which allows her to stay on track. She reported that she has trouble concentrating with online courses. KARINA noted she works as a substitute teacher. She reported that going to school and working has caused her anxiety. She specified that she works as a substitute teacher all week, then Tuesdays and Thursdays attends afternoon classes. KARINA noted that she is able to perform well at work; however, lacks motivation when she gets home.
Social/Activities: KARINA described herself as nice, friendly, and talkative. She reported she is very approachable. KARINA noted that school and work take up a significant amount of her time and doesn’t give her time to do other stuff. She also indicated that she has lost motivation and prefers to be at home. She reported that for fun she likes to spend time with her boyfriend.
Medical History: KARINA has seldom required medical care, except for typical childhood illnesses. She has not had any hospitalizations, operations, or urgent care. KARINA denied any medical condition. She reported no history of being prescribed medication. However, she reported taking medication such as over the counter natural pills to support brain health. She has trouble maintaining asleep. However, she also reported over sleeping. KARINA indicated she has gained a significant amount of weight and is constantly hungry. She stated, “I have a meal and then one hour later I am hungry again”.
Family Medical History: She denied any family history of mental illnesses.
Legal: She denied any legal history, including being in trouble with law, in jail, or lawsuit.
Substance Use: She reported drinking alcohol approximately every 3 months. Per. KARINA, she doesn’t drink much only on social gatherings. She denied any illicit drug use.
MEDICATIONS:
1. Over the counter: Natural pills
STRENGTHS/ WEAKNESSES
Strengths:
• Very adaptable
• Pushes herself to be better
Weaknesses:
• Overthinking
• Does not speak up for herself
• Lacks time management, late everywhere
ASSESSMENT OF MOOD AND PHYSICAL PROBLEM/SYMPTOMS (NOT ASSESSED)
Mood: ___No Change ____Increased ____Decreased
Sleep: ___No Change ____Increased ____Decreased
Interest/ Pleasure: ___No Change ____Increased ____Decreased
Motivation: ___No Change ____Increased ____Decreased
Energy: ___No Change ____Increased ____Decreased
Concentration: ___No Change ____Increased ____Decreased
Memory: ___No Change ____Increased ____Decreased
Appetite, Weight changes: ___No Change ____Increased ____Decreased
Self-Concept: ___No Change ____Increased ____Decreased
Anxiety / Worries: ___No Change ____Increased ____Decreased
RECENT/CURRENT SUICIDAL IDEATION:
Have you had thoughts of suicide or killing yourself? NO: She reported constantly questioning “why I am I here.” However, denied any current thoughts of suicide.
History of SI, plan, or attempts? NO
SCREENING RESULTS
PHQ-9 Score: 12 “Moderate Depression”
GAD7 Score: 10 “Moderate Anxiety”
MENTAL STATUS EXAM & BEHAVIORAL OBSERVATIONS
Appearance: Appears as her stated age, average height with a medium build
Attitude/ Approach: At the commencement of the interview KARINA appeared shy and guarded. However, as the interview progressed KARINA was cooperative and engaged.
Orientation: Fully oriented. She was oriented to time, place, and person throughout the evaluation process
Attention: Within normal limits.
Mood: Anxious and Depressed.
Affect: Within Normal Limits
Immediate Memory: Intact
Motor Activity: Unremarkable
Declarative Memory: Intact
Speech: Initially, she spoke in low volume. However, as the interview progressed she spoke in normal volume.
Fund of Knowledge: Average
Language Skills: Good aural comprehension
Thought Processes: Goal-Directed
Thought Content: Relevant to Topic
Hallucinations: None
Delusions Ideas: None
CLINICAL AND DIAGNOSTIC IMPRESSIONS
1. Generalized Anxiety Disorder
2. Unspecified Major Depression Disorder
3. Sibling Relational Problem
4. Psychosocial Stressors: isolation, negative sibling relationship, religious household, change in eating habits, change in sleep patterns, starting a masters program
5. RULE OUT diagnoses: Major Depression Disorder
TENTATIVE TREATMENT PLAN
1. The patient will be referred to counseling to address emotional and behavioral problems in the attempt to reduce symptoms regarding her anxiety. Continue to assess problem areas and develop treatment goals and plans. Scheduled for follow up session this week on 04/27/2022.
2. Continue to gather relevant information from client and complete clinical assessment to determine the focus of treatment.
3. Cognitive behavioral therapy is recommended to manage her behaviors and acquire new skills .
