Chief Complaint for Psychotherapeutic Assessment:

“I’m here for assessment for psychotherapeutic assessment for anxiety. I’ve been feeling extremely anxious and overwhelmed lately, affecting my daily life. I need help managing my anxiety and finding ways to cope with it.”

History of Present Illness (HPI) for Psychotherapeutic Assessment:

Patient: Initials: J.S.

Age: 68

Race: Caucasian

Gender: Female

Purpose of evaluation: Psychotherapeutic assessment for anxiety

Current medication: Not specified

Referral reason: Not specified

The patient, J.S., a 68-year-old Caucasian female, presents for psychotherapeutic assessment for anxiety. The patient reported experiencing anxiety symptoms and sought professional help to address her concerns. Unfortunately, the information does not provide specific details regarding the patient’s symptoms, duration, and severity.

Given the lack of information about the patient’s current medication and the absence of a referral reason, we would need additional investigation and assessment to understand the patient’s condition. Detailed documentation in this section is vital for effective patient care, accurate coding, and billing analysis.

 

 

Past psychiatric history for Psychotherapeutic Assessment:

The patient presenting with symptoms of anxiety is seeking a psychotherapeutic assessment. The onset of symptoms was approximately six months ago and has persisted. The patient describes experiencing frequent episodes of excessive worry, restlessness, irritability, difficulty concentrating, and muscle tension. These symptoms occur daily and are described as moderate to severe in intensity. The impact of these symptoms on the patient’s daily functioning is significant, as they report difficulties in work performance, relationships, and overall quality of life.

Past Psychiatric History: The patient previously received mental health treatment. They have undergone cognitive-behavioral therapy (CBT) in the past, which was their first treatment experience. Caregivers are not listed in this case.

This patient has had no reported hospitalizations, detoxifications, or residential treatments. They deny any history of suicidal or homicidal behaviors. There is also no history of self-harm behaviors.

Based on the presented symptoms, a differential diagnosis for this patient may include Generalized Anxiety Disorder (GAD), Panic Disorder, Social Anxiety Disorder (Social Phobia), and Adjustment Disorder with Anxiety. A comprehensive psychiatric review of systems (ROS) will be conducted to evaluate the patient further and rule out other potential psychiatric illnesses.

Medication trials and current medications for Psychotherapeutic Assessment:

During the patient’s medication trials, they were prescribed several psychotropic medications with different outcomes. Haloperidol was administered but resulted in a dystonic reaction, indicating an adverse reaction. Risperidone was tried, but the patient experienced hyperprolactinemia, suggesting another adverse reaction. On the other hand, olanzapine proved to be effective in managing the patient’s symptoms.

Unfortunately, despite its efficacy, the patient faced the obstacle of insurance coverage limitations preventing them from continuing to use olanzapine. These examples illustrate the patient’s mixed responses to psychotropic medications, including adverse reactions, effectiveness, and external factors like insurance restrictions impacting their treatment options. Such experiences emphasize the importance of carefully monitoring and evaluating medication choices, considering individual reactions, and addressing barriers to ensure optimal treatment outcomes for the patient.

Pertinent Substance Use:

Patient Substance Use History:

Caffeine: The patient reports regular caffeine use, primarily in coffee. The daily amount of caffeine consumption is approximately two cups of coffee per day. The patient’s last known use of caffeine was this morning.

Nicotine: The patient has a history of nicotine use. They report smoking cigarettes, and the daily amount of help is approximately five cigarettes per day. The last known use of nicotine was earlier today.

Illicit substances (including marijuana): The patient denies any current or past use of illegal substances, including marijuana.

Alcohol: The patient reports occasional alcohol use. They state that they consume alcohol socially on weekends, approximately two to three drinks per occasion. The last known use of alcohol was three days ago.

Withdrawal complications: The patient does not report any history of withdrawal complications such as tremors, Delirium Tremens, or seizures related to substance use.

Family Psychiatric/Substance Use History:

Psychiatric illness: The patient reports a family history of psychiatric illness. The details of specific psychiatric diseases within the family are not provided.

Substance use illnesses: The patient does not mention any known family history of substance use illnesses.

Family suicides: The patient does not mention any known family history of suicides.

Psychotherapeutic assessment for anxiety:

The patient presents with symptoms consistent with anxiety. A thorough assessment of the patient’s anxiety symptoms, including their frequency, intensity, and impact on daily functioning, is necessary to determine an appropriate treatment plan. Additionally, exploring any underlying causes or triggers for the anxiety and the patient’s coping mechanisms and social support will contribute to a comprehensive assessment. The psychotherapeutic intervention aims to address the patient’s anxiety symptoms, improve their overall well-being, and enhance their ability to manage and navigate stressful situations effectively.

Psychosocial History:

The patient was born in a city and was raised by their parents. They have one younger sister, making them the eldest sibling. The patient lives with their spouse in a house with two children.

The patient completed a bachelor’s degree in business administration. They enjoy reading, playing video games, and spending time with their family in their leisure time.

The patient is currently working as a marketing manager in a corporate setting. There are no indications of disability, unemployment, or retirement. There is no reported legal history, indicating no past issues or current legal problems.

Regarding trauma history, the patient experienced childhood trauma in the form of emotional and verbal abuse. They have engaged in therapy to address these experiences and have shown progress in their healing journey. There are no recent traumatic events reported.

No concerns or issues about the patient’s safety in personal, home, or community settings exist. There is no history of sexual violence or any current concerns in that regard.

Medical History:

The patient has a generally good medical history with no significant illnesses reported. There have been no major surgeries. There is no history of seizures or head injuries.

Current Medications:

The patient is not currently taking any medications for anxiety or other conditions. There are no reported OTC or homeopathic products used for anxiety management.

Allergies True Reaction vs. Intolerance with Psychotherapeutic Assessment:

1. Medication Allergies:
   • Description: Immune system reacts adversely to medications, causing symptoms like hives, itching, swelling, and potentially anaphylaxis.
   • Psychotherapeutic assessment: Assess anxiety related to true medication allergy vs. intolerance, considering symptoms and fear of reactions.
2. Food Allergies:
   • Description: Immune system reacts to specific proteins in food, leading to symptoms like hives, swelling, gastrointestinal distress, and anaphylaxis.
   • Psychotherapeutic assessment: Evaluate anxiety concerning genuine food allergy vs. intolerance, considering symptoms and fear of reactions.
3. Environmental Allergies:
   • Description: Immune system overreacts to environmental allergens (pollen, dust mites, etc.), causing symptoms like sneezing, itching, congestion, and asthma exacerbation.
   • Psychotherapeutic assessment: Explore anxiety related to actual environmental allergies vs. intolerance, considering symptoms and fear of allergic responses.

ROS Report;

General: There was no significant fatigue or changes in appetite reported.

Reproductive: No heavy bleeding or significant pain was reported during the menstrual period and it occurred regularly for 28 days, lasting 5 days.

Obstetric/Gynecologic: there were complications while giving birth, but no postpartum depression or significant emotional adjustment was reported.

Psychiatric: No history of anxiety or depression. Currently experiencing occasional low mood and irritability.

Social/Family: Both the partner and close friends give good social support with no major events or stressors at the moment.

Medical/Surgical: Of late there have been no significant medical conditions or surgeries nor any medications being taken.