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Psychiatry . . . Page 4


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Edited Sample Report

History of Present Illness

This patient is a married Caucasian female who was sexually molested by her mother's boyfriend at age five and by her cousin between the age of ** and **. She used to suffer from recurrent nightmares and feelings of disgust about sex.

She also mentioned that she has been feeling depressed, sad, unhappy, withdrawn, apathetic, lacking energy and ambition to do much since her teen years periodically.

She also has had fear of germs for many years. Her husband cannot even sneeze around the house without getting unduly worried about catching a viral infection.

Medical History
Is significant for chronic sinusitis, peptic ulcer disease, obesity, and premenstrual dysphoric disorder.

Family History
Is significant for postpartum depression with one of her cousins.

Medication
Antihistamines for the management of chronic sinusitis.

Personal History
Full term normal delivery. Milestones of development were normal. Early childhood was marked by adverse sexual encounters and experiences. However, she managed to complete high school. She was not sexually active until **.

This patient denied any alcohol or elicit drug abuse.

Current Mental State
She is pleasant and cooperative. She is alert and responsive. Her orientation is full for time, place and person. Mood is depressed. Affect is flat. Thinking is logical. Thought content is informative. She is not actively suicidal. Sometimes, she feels very despondent. No hallucinations noted. She does have phobias for germs. No obsessions or compulsions noted. Memory is intact for past and recent events. Delayed recall is good at 30 minutes. She is of average intelligence. When depressed her energy level goes down. She manifests with symptoms of anxiety, reversal of vegetative symptoms by way of increased appetite, weight gain, increased levels of anxiety, disinterest in sex, concern with fear of germs, etc.

She has some insight into her present state and her judgement is fair.

Assessment
Axis I -- Major depression, recurrent. Premenstrual dysphoric disorder. Phobic disorder. Sexual dysfunction disorder.
Axis II -- Personality disorder, avoidant type.
Axis III -- Chronic sinusitis, obesity, peptic ulcer disease.
Axis IV -- Moderately-severe psychosocial stress.
Axis V -- GAF is 60.

Plan
I have advised this patient to go on Zoloft, 50 mg q.d. and increase the dosage to 100 mg q. d. during the coming week. Zoloft should be beneficial in treating the atypical depression, phobic disorder as well as premenstrual dysphoric disorder. Once these are under control, a few sessions of supportive psychotherapy and counselling, should be helpful in ameliorating some of her difficulties associated with early childhood trauma. To this effect, I'll see her on a few occasions at my office.

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Edited Sample Report

This patient  is a **-year-old married lady who has been feeling very depressed, sad, unhappy, withdrawn, apathetic, lacking energy and ambition to do anything on and off for many years. Lately, these symptoms have gotten progressively worse and she has become dysfunctional. This lady is also experiencing recurrent anxiety attacks, panic attacks, and a general feeling of nervousness.

She states that suffers from recurrent headaches. Some of them are clearly muscle tension headaches and others are characterized by aura, followed by unilateral headache with symptoms of nausea, photophobia, etc.

The patient lost her mother at the time of her wedding due to brain hemorrhage.

Her father is alive and in good health.

She is married for ten years. Her husband sustained a back injury. As a result, he could not return to work so far. She has children aged ** and ** year of age. Following the birth of these children she did suffer from what appears to be a postpartum depression.

At present, she is working as a *** and she does enjoy her work.

Medication
Imitrex, atenolol, lithium carbonate, and Imovane.

Current Mental State
This patient is pleasant and cooperative. She is alert and responsive. Her orientation is full for time, place and person. Her mood is depressed and sustained. Affect is flat. Thinking is logical. Thought content is informative. There is no evidence of delusions or suicidal ideation. Her concentration is impaired on serial 7s.

Memory is intact for past and recent events. Delayed recall is good at 15 minutes. No obsessions, compulsions or phobias noted. She does have anxiety/panic attacks. She denies any hallucinations. She has some insight into her present state and her judgement is intact.

Assessment
Axis I -- Major depression, recurrent of postpartum onset. Panic disorder without agoraphobia.
Axis II -- No problems identified.
Axis III -- Migraine headaches with aura.
Axis IV -- Moderately-severe psychosocial stress.
Axis V -- GAF is 60.

Plan
Suggest that we discontinue lithium carbonate and Imovane. Suggest that we start her on Zoloft, 50 mg a day and increase the dosage to 100/150 mg a day based on her tolerance and response. Start on Rivotril, 0.5 mg q. h.s. For now, she could continue with Imitrex and atenolol.

I will review her at my office during the coming 2-3 weeks. Prognosis good.

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