Comprehensive psychiatric evaluation intake

Comprehensive psychiatric evaluation intake

Patient Information

Patient Initials: S.C   Age: 40 years    Sex: Female    Date: 01/07/2026

Subjective:

Chief Complaint (CC): “I have been feeling so depressed and anxious, and I simply want to feel like myself again.”

HPI: S.C. is a 40-year-old woman who presents with complaints of persistent depressive symptoms, anxiety, and grief-related distress. She complains of depressed mood most days over the last several months, and it has gotten a lot worse recently following the death of a close friend, whom she refers to as a mother figure. The symptoms include low motivation and fatigue, loss of interest in activities and social withdrawal, poor concentration, disturbed sleep pattern with frequent night awakenings, and loneliness. She denies present suicidal ideation, intent or plan. The patient also presents with a history of chronic anxiety which includes excessive worry, restlessness, muscle tension, and intermittent panic attacks. She reports having had panic attacks in the past, when driving her bus, which makes her fear that she might lose control and feel short of breath, although she denies any recent attacks severe enough to make her unable to work. She has a history of opioid use disorder, which is presently under control with buprenorphine-naloxone, and has a high desire to stay abstinent. She reports that continuity of care and medication access is a concern because of recent insurance changes since her old PCP no longer accepts her insurance. She is trying to find psychiatric assistance for medication management and psychotherapy.

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Past Medical History (PMHx):

1. General Statement: The patient has a history of depression and anxiety that has been managed to a considerable degree over 15 years by her primary care provider.
2. Caregivers: Not applicable
3. Hospitalizations: The patient denies past psychiatric hospitalization.
4. Medication Trials: Trials in the past have comprised risperidone (withdrawn owing to the emergence of a generalized rash), hydroxyzine in panic disorders, and clonazepam. Current medications are gabapentin, clonidine, and buprenorphine-naloxone Comprehensive psychiatric evaluation intake
5. Psychotherapy or Past Psychiatric Diagnosis: Major depressive disorder, generalized anxiety disorder, panic attacks, and opioid use disorder. Minimal psychotherapy history; no history of regular long-term therapies.
6. Substance Current Use History: The patient has a history of opioid use disorder with Percocet and other prescription opioids and some cocaine use in early adulthood. She states that she has had about 15 years of sustained remission with occasional two or three-day long relapses. She is up-to-date on buprenorphine-naloxone therapy and denies the use of illicit substances. She admits no present alcohol abuse and infrequent social use of alcohol. She denies tobacco use.

Family History:

• Mother: Alive, early 60s, untreated anxiety history, emotionally strained relationship with the patient.
• Father: Alive, middle-60s; poor emotional attachment, no psychiatric history.
• Maternal Grandmother: Deceased; history of depression.
• Paternal Grandfather: Deceased; history of alcohol use disorder.
• Denies family history of suicide.

Psychosocial History: The patient works full time as a bus driver and has been working in this position over the last 10 years. She resides with her daughter and reports that she is financially stable but emotionally isolated. She maintains a poor relationship with her parents and has very few social support networks, mostly a neighbor and family of her deceased friend. She lacks hobbies or activities and spends most of her time at home other than work. She discloses a history of unplanned gambling, but this has greatly been getting better since a big win last year. She denies legal problems or existing interpersonal violence.

Medical History: History of dental extraction with dentures, history of chronic phantom tooth pain, history of a severe skin infection that necessitated antibiotics and topical mupirocin. No endocrine disorder, cardiovascular disease, or history of seizures.

Current Medications

• Buprenorphine-naloxone 8-2 mg SL film, one film every day.
• Gabapentin 800 mg PO three times each day.
• Clonidine 0.1 mg PO daily
• Ibuprofen when necessary in case of pain.

Allergies:

• Medication: Risperidone: rash.
• Food: None known.
• Environmental: No known allergy.

Reproductive History: Gravida 1, Para 1. Regular menstrual cycles. No current pregnancy. Denies hormonal contraception.

Review of Systems (ROS):

• GENERAL: Complains of sleep disturbances, loss of energy and fatigue.
• HEENT: Wears dentures, occasional oral pain reported.
• SKIN: No rashes or lesions; history of skin infection.
• CARDIOVASCULAR: Denies myocardial palpitations with panic attacks.
• RESPIRATORY: Denies persistent cough, dyspnea other than during panic attacks.
• GASTROINTESTINAL: Appetite poor; denies nausea or vomiting.
• GENITOURINARY: No complaints of urinary problems.
• NEUROLOGICAL: Denies seizures or syncope; complains of difficulty concentrating.
• MUSCULOSKELETAL: Tension of the muscles with anxiety.
• HEMATOLOGIC: No anemia or bleeding history.
• LYMPHATICS: Denies any swelling of lymph nodes.
• ENDOCRINOLOGIC: Denies heat/cold intolerance or polyuria.

1. OBJECTIVE

• General Appearance: The patient is 40 years old, appearing her stated age, attentive and cooperative, casually dressed with a slightly unkempt grooming, slightly bent posture, and mild psychomotor retardation. No acute distress observed.
• Vital Signs: BP 130/82 mmHg, HR 96 bpm, RR 18/min, Temp 98.6°F, SpO₂ 98% on room air.
• Head/Eyes/Ears/Nose/Throat: Head is atraumatic, scalp and hair are intact. Symmetrical eyes, reactive and equal pupils, EOMI, intermittent eye contact, normal hearing. Nares patent, septum midline. Oral mucosa moist; dentures fitting appropriately, no lesions or infection; pharynx non-erythematous.
• Neck: Supple, no lymphadenopathy, thyromegaly, or masses. Trachea midline.
• Cardiovascular: Regular rate and rhythm, S1/S2 audible, no murmurs/rubs/gallops. Peripheral pulses palpable and symmetrical, no edema.
• Respiratory: Bilateral symmetric chest expansion, bilateral clear breath sounds, no dyspnea.
• Gastrointestinal: Abdomen soft, non-tender, non-distended; bowel sounds present; decreased appetite, no pain.
• Genitourinary: Deferred; patient denies dysuria, hematuria, or incontinence.
• Musculoskeletal: Full ROM, mild shoulder/neck tension, steady gait, no joint deformities or swelling.
• Neurological: Alert and oriented x4, cranial nerves II–XII grossly intact, strength 5/5, sensation intact, no tremors or focal deficits.
• Skin: Warm, dry, intact; no rashes, lesions, or track marks.
• Psychiatric/Behavioral Observation: Anxious but cooperative, constricted affect congruent with mood, speech soft but coherent, logical thought processes, no hallucinations or delusions.

Diagnostic results:

• Complete Blood Count (CBC): Tests anemia or infection that can be a cause of fatigue, low energy, and depressive symptoms (Seo and Lee, 2022).
• Comprehensive Metabolic Panel (CMP): Tests kidney and liver functionality to ascertain the safety of the continuation of gabapentin and buprenorphine-naloxone (Togioka and Patel, 2024).
• Thyroid-Stimulating Hormone (TSH): Rules out thyroid dysfunction which may either replicate or aggravate depression and anxiety (Fan et al., 2024).

1. ASSESSMENT

Mental Status Examination:

The patient is a 40-year-old woman who looks her stated age and is casually dressed with season-appropriate clothing. There is slight neglect of grooming, and slightly dishevelled hair. She is cooperative and active during the interview, but has a slightly bent posture and slowed psychomotor activity, indicative of low energy. Her speech is soft in volume, slow rate, and coherent, with clear articulation and no pressure or latency. She reports her mood as depressed and anxious and her affect constricted with limited range, but congruent with the content of discussion. Thought is linear, logical and goal-oriented, and the thought content is marked by grief-related rumination, loneliness and excessive worry. She denies any delusions, paranoia, obsessions, hallucinations or perceptual disturbances. The patient reports no suicidal/homicidal thoughts, will, or intention. She is alert and oriented to person, place, time and situation. There is mild impairment of attention and concentration, as the she sometimes has trouble keeping focus, but immediate, recent, and remote memory are intact. There is fair insight into her mental health status, the judgment is intact, impulse control is adequate, and she shows motivation to participate in treatment and enhance her overall functioning.

Differential Diagnoses:

1. Major Depressive Disorder, Recurrent, Moderate (ICD-10: F33.1).

Major Depressive Disorder refers to a mood disorder and is marked by perennial depressive mood, lack of interest or pleasure, and functional deterioration (Bains and Abdijadid, 2023). The DSM-5 criteria include five or more symptoms in the same 2-week period, including depressed mood or anhedonia, accompanied by sleep disturbance, reduced energy, impaired concentration, or worthlessness, which leads to severe distress (American Psychiatric Association, 2022). This patient is eligible because of persistent low mood, social withdrawal, fatigue, insomnia, and grief-related rumination, which affects working and home life. Although there is no history of psychiatric hospitalization or attempts to commit suicide, the severity and functional impairment favor this as the main diagnosis.

2. Generalized Anxiety Disorder (ICD-10: F41.1).

GAD is characterized by anxiety and worry experienced more days than not for at least six months, which is accompanied by symptoms of restlessness, fatigue, inability to concentrate, irritability, muscle tension, and sleep disturbance (American Psychiatric Association, 2022). The patient experiences persistent worry, muscle tension, restlessness and occasional panic attacks, which have an impact on occupational functioning. The symptoms of anxiety are noticeable and distressing, yet they could be a side effect of her depression and grief, and the length is not entirely adequate to fit the criteria of chronicity in DSM-5.

3. Panic Disorder (ICD-10: F41.0)

Panic Disorder can be described as a set of repeated and sudden panic attacks and constant worry or behavioral change concerning the attacks. DSM-5 demands the presence of one or more panic attacks, as well as at least one month of concern or behavior change (Cackovic et al., 2023). The patient states that she had previously experienced panic attacks during her bus ride, which made her feel uncomfortable. However, her attacks are rare, circumstantial, and have not recently affected her functioning, which reduces Panic Disorder as a primary diagnosis.

4. Opioid Use Disorder, In Sustained Remission (ICD-10: F11.21).

Opioid Use Disorder is characterized as a dysfunctional pattern in opioid consumption that causes substantial disruption or distress (Dydyk et al., 2024). During a lasting remission, there is no diagnostic condition for at least 12 months. This patient has a prior history of opioid use disorder that has been in remission for 15 years with few and temporary relapses, and is compliant with buprenorphine-naloxone treatment. Although it is essential in treatment planning, it fails to explain her present depressive and anxiety symptoms and is regarded as a secondary historical diagnosis.

Critical Thinking Process Leading to the Primary Diagnosis

Major Depressive Disorder, Recurrent, Moderate was considered the primary diagnosis based on the assessment of the duration of symptoms, functional impairment, and the DSM-5 criteria. Although grief, anxiety, and prior substance use are evident, the pervasive low mood, anhedonia, fatigue, insomnia, and social withdrawal in the patient are severe and result in considerable impairment of occupational and social functions. Symptoms of grief and anxiety can be addressed as secondary contributors, which leads to the selection of MDD as the focus of treatment and management Comprehensive psychiatric evaluation intake

REFLECTION:

This case under consideration demonstrates the complicated relationship between grief, depression, anxiety, and substance use disorder history. My “aha” moment was when I realized that the recent loss of a close friend was worsening her depressive symptoms and social withdrawal, and her long-term opioid use disorder recovery was a sign of resilience that could be used as a strength during the treatment process. I concur with the preceptor’s assessment that she is not at high risk of self-harm, and the primary diagnosis of Major Depressive Disorder with anxiety and grief as secondary factors. In managing this case, I would have considered more social support, including grief groups, peer support programs, or community resources, to minimize the effects of isolation and maximize coping. The social determinants of health that may affect her care are poor social support, poor relationship with family, and difficulty in accessing healthcare because of insurance problems. These factors can be managed by linking her to affordable mental health services, promoting continuity of care, and enhancing her social network via community and peer-based interventions, which can be helpful in addressing her emotional health and recovery aims.

References

Baddam, S., & Tubben, R. E. (2023). Lactic acidosis. National Library of Medicine; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK470202/

Brihi, J. E., & Pathak, S. (2024, June 8). Normal and abnormal complete blood count with differential. Www.ncbi.nlm.nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK604207/

Dowell, D., Ragan, K., Jones, C., Baldwin, G., & Chou, R. (2022). CDC clinical practice guideline for prescribing opioids for pain. MMWR. Recommendations and Reports, 71(3), 1–95. https://doi.org/10.15585/mmwr.rr7103a1

Grigorean, V. T., Erchid, A., Coman, I. S., & Liţescu, M. (2023). Colorectal cancer—The “parent” of low bowel obstruction. Medicina, 59(5), 875. https://doi.org/10.3390/medicina59050875

Kaur, K., Adamski, J. J., & Zubair, M. (2023, April 23). Fecal occult blood test (Hemoccult). PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK537138/

Nelms, D. W., & Kann, B. R. (2021). Imaging modalities for evaluation of intestinal obstruction. Clinics in Colon and Rectal Surgery, 34(4). https://doi.org/10.1055/s-0041-1729737

Nies, K., Vernooij, R., Devriese, L., Venhuizen, J.-H., ten Berg, M., Swart, C., Lammers, L., & Haitjema, S. (2025). Chemotherapy-induced hematological toxicity in patients with renal or hepatic impairment. Pharmaceutics, 17(10), 1280. https://doi.org/10.3390/pharmaceutics17101280

Schick, M. A., Meseeha, M., & Kashyap, S. (2025, January 19). Small bowel obstruction. National Library of Medicine; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK448079/

Sizar, O., Gupta, M., & Genova, R. (2023, August 7). Opioid induced constipation. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK493184/

Tans, A., Struyf, T., Geboers, R., Smeets, T., Asselbergh, Y., Declerck, E., Bloemen, L., & Ann. (2024). Signs and symptoms of serious illness in adults with acute abdominal pain presenting to ambulatory care: a systematic review. BJGP Open, BJGPO.2023.0245–BJGPO.2023.0245. https://doi.org/10.3399/bjgpo.2023.0245

Comprehensive psychiatric evaluation intake

Class: Psychpathology Diag Reason Prc-Winter 2025 .
This is a new intake. The instructions are under Week 7: Assignment 2, Part 1
Please follow the Comprehensive Psychiatric Evaluation exemplar, Take a look at the score rubic please. Feel free to add to the case for some information that may be missing.

S.C. 40 yr old Female
The patient presents for a new visit and reports significant depressive symptoms, anxiety, and a history of substance use on opioids and cocaine. She is seeking to improve her mental health and regain a sense of normalcy in her life. The patient has expressed a desire to feel better and has reported a lack of motivation and social withdrawal, particularly following the loss of a close friend. The prescriber will continue to monitor the patient’s medication regimen and provide support as needed. The patient has a stable medication history but is concerned about potential changes due to insurance issues. The patient has not been hospitalized for psychiatric reasons and has no current thoughts of self-harm or harm to others, indicating a low risk for acute psychiatric crises. Her PCP was the prescriber for all her medications for 15 yrs until the PCP could no longer accept the pt.’s health insurance

The patient is a 40-year-old bus driver who has been in this profession for ten years. She lives alone with her daughter and has a strained relationship with her parents, particularly her mother. The patient has a limited support network, primarily consisting of a neighbor and a deceased friend’s family. The patient reports feeling isolated and does not engage in social activities outside of work, spending most of her time at home. She has a history of impulsive behavior related to gambling, which has improved since winning a significant amount of money last year. The patient has no legal involvement reported Comprehensive psychiatric evaluation intake

Past Psychiatric History:
The patient has a history of opioid use disorder, primarily using Percocet and other prescription medications, including clonazepam and gabapentin. She has been clean for approximately 15 years, with some relapses lasting no more than two to three days. The patient has been prescribed various medications for depression and anxiety, including risperidone, which was discontinued due to side effects (rash), and hydroxyzine for panic attacks. The patient reports that gabapentin was prescribed for depression and has been taking it for about two years. The patient has not been hospitalized for suicidal ideation or attempts and has no current thoughts of self-harm. The patient has experienced panic attacks that have affected her ability to drive a bus, and she reports a significant depressive episode following the death of a close friend in April of this year

Past Medical History:
The patient has a history of dental issues leading to the extraction of all teeth and the use of dentures. She has experienced phantom tooth pain and has been prescribed ibuprofen as needed. The patient also had a significant infection in the past that required antibiotics and topical treatment with mupirocin. No other significant medical history is reported.

Risk Assessment:
The patient does not express any current thoughts of self-harm or harm to others and has never attempted suicide. She reports no history of psychiatric hospitalizations. There are no immediate risk factors present, and the patient has a supportive network, although she does not have close relationships with family members. The patient has access to medications, including opioids and benzodiazepines, but there is no indication of misuse at this time. The prescriber assessed for risk during the session and confirmed that the patient is not an imminent threat to herself or others.

Vitals BP 130/82, RR 18, Temp 98.6, Pox 98%, HR 96

Medications:
Buprenorphine-naloxone 8-2 mg film. One film under tongue (SL) twice a day for Opioid use disorder.
Clonidine HCl (clonidine hcl) 0.1 mg tablet. One tablet po once a day for Anxiety.
Gabapentin 800 mg tablet. One tablet po three times a day for Anxiety.

Referrals: Refer the patient to a therapist for ongoing psychotherapy to address depression and anxiety.

Education: Educate the patient on the importance of managing anxiety and depression, including recognizing triggers and coping strategies.

Psychotherapy: Encourage the patient to engage in therapy to help process grief and develop strategies for managing depressive symptoms.

Summary:
– Patient is managing opioid use disorder, depression, and anxiety; significant loss of a mother figure-like friend exacerbating symptoms.
– Strained relationship with mother contributing to emotional distress; history of past gambling addiction.
– No current suicidal ideation or self-harm intentions; risk assessment conducted.
– Discussed medication management; pt. is on clonazepam, gabapentin, Suboxone; considering dosage adjustments.
– Used Motivational Interviewing and psychoeducation; pt. is open to connecting with a therapist at the facility.
– Plan: Follow-up in 28 days, monitor medication, encourage blood work completion before next session Comprehensive psychiatric evaluation intake