PSYCHOLOGICAL EVALUATION
ROBERT F. FIERSTEIN, Ph.D.
Patient Name: VICTORIA ROMAN
#12688571
Date: JANUARY 25, 2017
2017 EVALUATION
Referral: DUANE SPIKER, M.D.
PSYCHIATRIST
Accompanied by: SELF ONLY
CHIEF COMPLAINT: VERY DEPRESSED, CRYING, OVER EATING, WEIGHT GAIN, CAN'T GET OUT OF BED IN THE MORNING, WANTS TO SLEEP ALL DAY, AND FEELS HOPELESS ABOUT HER FUTURE.
SYMPTOMS
Sleep: VERY POOR SLEEP PATTERN. SLEEPS A LOT. SLEEPS IN AND SLEEPS DURING THE DAY. FEELS TOO DEPRESSED TO GET OUT OF BED.
Interests: HAS LOST INTEREST IN THE ACTIVITIES THAT SHE USUALLY DOES. SHE IS NOT SOCIALIZING WITH HER FRIENDS AND NOT DOING THE CREATIVE THINGS SHE LIKES TO DO.
Guilt: FEELS VERY GUILTY BECAUSE SHE HAS CUT OFF HER FAMILY AND FRIENDS. SHE DOES NOT WANT TO BE AROUND THEM BECAUSE SHE'S SO DEPRESSED ALL THE TIME.
Energy: SHE DOESN'T HAVE A LOT OF ENERGY AND SHE WOULD RATHER SLEEP THAN BE AWAKE. EVERYTIME SHE WAKES, SHE FEELS TOO TIRED TO GET OUT OF BED. SHE HAS NO ENERGY TO DO HER HOUSEHOLD RESPONSIBILITIES LET ALONE GO OUT WITH FRIENDS.
Concentrating: SHE SAYS SHE HAS DIFFICULTY FOCUSING ON THINGS. SHE CAN'T CONCENTRATE ON ANYTHING FOR ANY LENGTH OF TIME. SHE SAYS SHE GOES OFF ON TANGENTS AND CAN'T STAY FOCUSED ON HARDLY ANYTHING.
Appetite: PATIENT STATES THAT HER APPETITE IS TOO GOOD AND SHE CANNOT STOP EATING SWEETS. SHE IS ASHAMED OF HERSELF FOR EATING SOME MUCH BUT ITS ONE OF HER ONLY SOURCES OF ENJOYMENT. SHE KNOWS SHE SHOULD GO ON A DIET, BUT DOES NOT FEEL MOTIVATED TO DO SO.
Suicidal Ideation: THE PATIENT STATES THAT SHE WOULD NEVER HURT HERSELF. SHE IS A RELIGIOUS PERSON AND THINKS GOD WOULUD BE UNHAPPY WITH HER IF SHE DID SOMETHING TO END HER LIFE. SHE SAYS , HOWEVER, THAT IF GOD TOOK HER FROM THIS EARTH SHE WOULD NOT CARE.
Homicidal Ideation: THE PATIENT SAYS SHE IS NOT AN AGGRESSIVE PERSON TOWARDS OTHER AND WOULD NEVER THINK OF HURTING OR KILLING ANYONE. SHE DOES FEEL FRUSTRATED AND ANGR WITH HER LIFE BUT WOULD NOT BLAME OR HURT OFTHERS.
Mood (range 0-10): 0-5 AS MOST OF THE TIME SHE FEELS MORE DEPRESSED THAN UP AND HAPPY.
BEHAVIORS
Patient history of...
Lying
Stealing
Physical Aggression
Fire Setting
Truancy
Forced Sexual
Cruelty - Animals
Running away
Oppositional/Defiant
Drugs
Details of behaviors selected: THE PATIENT SAYS SHE DOES NOT HAVE ANY OF THESE BEHAVIORS IN HER HISTORY. SHE SAYS THAT SHE USED TO BE A GOOD PERSON AND DIDN'T ACT OUT. MAYBE FROM TIME TO TIME SHE WAS A BIT OPPOSITIONAL TO HER FAMILY, BUT FOR THE MOST PART SHE WAS TOO NICE AND PASSIVE.
Stressors: PATIENT DESCRIBES NUMEROUS STRESSORS SUCH AS FINANCIAL AND MULTIPLE HEALTH PROBLEMS AND DOCTORS VISITS. SHE ALSO PROVIDES CHILD CARE TO HER 3 GRANDCHILDREN BECAUSE SHE FEELS HER DAUGHTER IN LAW IS NOT A VERY NURTURNING MOTHER. SHE IS FEELING STRESSED AND OVERBURDENED BY THE RESPONSIBILITY OF CARING FOR 3 CHILDREN, UNPAID.
HISTORY OF CHIEF COMPLAINT: PATIENT HAS DESCRIBED A HISTORY OF FEELING DEPRESSED AND ANXIOUS. SHE GREW UP IN A TUMULTUOUS FAMILY AND HER MOTHER WAS ALSO VERY STRESSED OUT WITH 7 CHILDREN AND WAS ALWAYS VERY ANGRY. BUT HER DEPRESSION IN RECENT YEARS HAS BEEN MUCH WORSE.
MEDICAL HISTORY: PATIENT HAS HAD A HISTORY OF RHEUMATOID ARTHITIS, BURSITIS, ASTHMA, COPD AND HAS HAD BOTH KNEES REPLACE.
Allergies: SHE REPORTS AN ALLERGY TO DUST AND POLLEN.
Medications: PATIENT IS TAKING 100 MG OF ZOLOFT AND 1MG OF XANAX. SHE IS TAKING METHOTREXATE, INHALERS, ENBREL FOR RA AND ZORELTO.
Medical History:
Surgical History: NO SURGICAL HISTORY REPORTED EXCEPT FOR TWO KNEE REPLACEMENTS.
Head Trauma/Loss of Consciousness: THOUGH PATIENT WAS IN A SERIOUS CAR ACCIDENT, THERE WAS NO LOSS OF CONSCIOUSNESS REPORTED, NOR HEAD TRAUMA.
FAMILY HISTORY
Father: NAMED WILLIAN RECENTLY DIED AT THE AGE OF 90 YEARS OLD. HE WAS EMPLOYED AS A TRUCK DRIVER AND WAS NOT HOME VERY MUCH. PATIENT SAID HE WAS A GOOD PROVIDER. HIS HEALTH WAS GOOD OVERALL. PATIENT FELT CLOSE TO HIM.
Mother: NAME KATHRYN AND DIED LAST YEAR AT THE AGE OF 90. SHE HAD BEEN IN A NURSING HOME DIAGNOSED WITH ALZHEIMER'S DISEASE. PATIENT DID NOT HAVE A GOOD RELATIONSHIP WITH HER BECAUSE SHE WAS ANGRY A LOT AND AT TIMES MEAN. SHE GOT CLOSER TO HER MOM WHEN SHE WAS IN THE NURSING HOME.
Paternal Grandfather/Grandmother: NO INFORMATION PROVIDED
Maternal Grandfather/Grandmother: NO INFORMATION PROVIDED
Maternal Aunts/Uncles: NO INFORMATION PROVIDED
Paternal Aunts/Uncles: NO INFORMATION PROVIDED.
SOCIAL HISTORY
Social Summary: PATIENT REPORTS HAVING A FEW GOOD FRIENDS. SINCE BEING DEPRESSED SHE HAS NOT SEEN HER FRIENDS. SHE SAYS THEY ARE UPSET WITH HER BECAUSE SHE IS NOT TAKING ENOUGH TIME FOR HERSELF AND SHOULD NOT BE BURDENED WITH CARING FOR HER GRANDCHILDREN. THE PATIENT IS A MEMBER OF AARP AND DOES OCCASSIONALLY ATTEND MEETINGS, BUT HAS BECOME MORE SOCIALLY ISOLATED AS A RESULT OF BEING DEPRESSED.
Problems with any of the following:
Friends
FINANCES
CHILD CARE
Details of problems selected: PATIENT HAS HAD DIFFICULTY MAINTAINING FRIENDSHIP BECAUSE SHE HAS NO TIME DUE TO HER CHILD CARE RESPONSIBILITIES. SHE HAS FINANCIAL ISSUES DUE TO A DIVORCE AND ALSO LIVING ON A FIX INCOME. AND HER PROBLEM WITH CHILD CARE IS THAT HER DAUGHTER IN LAW IS NOT "A GOOD MOTHER" AND THE PATIENT FEELS SHE MUST COMPENSATION FOR HER INADEQUACIES.
WORRIES: SHE WORRIES ABOUT HER GRANDCHILDREN AND HOW THEY ARE BEING TREATED BY THEIR MOTHER; WORRIED ABOUT HER SON WHO HAS PROGRESSIVE MS; WORRIES ABOUT SURVIVING FINANCIALLY. CONCERNED ABOUT HER HEALTH AND BEING ABLE TO AFFORD MEDICATIONS.
WISHES: SHE JOKING SAYS THAT SHE WANTS TO WIN THE LOTTERY SO THAT SHE CAN HAVE A BETTER LIFE AND TAKE CARE OF ALL HER FAMILY AND FRIENDS.
PEERS: AS STATED ABOVE, THE PATIENT SAYS SHE HAS FEW FRIENDS BUT DOES NOT SPEND MUCH TIME WITH THEM. HER DEPRESSION MAKES HER FEEL MORE LIKE A SOCIAL ISOLATE AND SHE STAYS AWAY FROM PEOPLE.
Long Term Goal: THE PATIENT'S BIGGEST GOAL IS TO STAY HEALTHY. SHE HAS LIMITATIONS BUT CONTINUES TO PUSH HERSELF ESPECIALLY WHEN IT COMES TO CARING FOR HER GRANDCHILDREN. SHE IS HOPING WHEN THEY GO TO SCHOOL THAT SHE WILL HAVE MORE TIME TO LIVE HER LIFE MORE FREELY.
Sexual Oreintation: HETEROSEXUAL
Heterosexual
Homosexual
Bisexual
Undecided
Sexually Active: NO AT THIS TIME
Mental Status Examination
Affect: FLAT, BLUNTED, ODD, QUIET AND WITHDRAWN
Mood: MORE DOWN, DEPRESSED, SAD, LETHARGIC, APATHETIC, ANXIOUS AND AGITATED.
Speech: SPARSE, REDUNDANT, LOGICAL AND ORGANIZED AND SUPERFICIAL.
Thought: ORGANIZED, LOGICAL, NO DELUSION/PSYCHOTIC CONTENT, MORE CONCRETE AND LESS INTELLECTUAL.
Memory: PATIENT'S SHORT, INTERMEDIATE AND LONG TERM MEMORY SPHERES APPEAR TO BE INTACT. PATIENT REPORTS BEING FORGETFUL. AGE RELATED COGNITIVE DEFICITS MAY BE PRESENT.
Judgement: PATIENT'S ABILITY TO MAKE GOOD DECISIONS ESPECIALLY REGARDING HER OWN WELL BEING APPEARS TO BE MILDLY TO MODERATELY IMPAIRED. SHE SAYS SHE NEEDS OTHER PEOPLE TO HELP HER MAKE BIG OR DIFFICULT DECISIONS.
Insight: PATIENT HAS FAIR INSIGHT AND LESS INSIGHT INTO HER OWN FUNCTIONING AND THE CAUSES. SHE IS A GOOD LISTENER, BUT NOT ALWAYS ABLE TO ASSIMILATE WHAT IS BEING SAID TO HER AND APPLY THE INFORMATION TO HER IMMEDIATE SITUATION.
Intelligence: PATIENT HAS NORMAL INTELLIGENCE. THERE IS NO EVIDENCE OF IMPAIRED INTELLIGENCE. SHE SUGGESTS THAT SHE NEVER REALLY MET UP TO HER POTENTIAL FOR WHICH SHE REGRETS.
Abstraction: PATIENT'S ABILITY TO ABSTRACT OR ENGAGE IN ABSTRACT THINKING IS LIMITED AND PREVENTS HER FROM MAKING CERTAIN LIFE STYLE CHANGES THAT WOULD BE BENEFITICAL TO HER LIFE.
DIAGNOSIS: CHRONIC MAJOR DEPRESSION (296.33), GENERALIZED ANXIETY (300.02) AND R/O PANIC DISORDER (300.01)
PROGNOSIS: MODERATE DEGREE OF OPTIMISM IF PATIENT GETS MEDICATIONS RE-EVALUATED AND BEGINS APPLYING COGNITIVE RESTRUCTURING TO HER EVERYDAY THINKING PROCESS.
Name
First Name
Last Name
Submit
Interests: CREATIVE ARTS. ROLE OF TREASURY AT AARP.
RECOMMENDATIONS: A. SEE PCP FOR RE-EVALUATION OF ANTI-DEPRESSANT. B. JOIN A SUPPORT GROUP FOR OVER EATERS. C. JOIN WEIGHT WATCHERS. D. JOIN A DEPRESSION SUPPORT GROUP. E. INCREASE HER THERAPY VISITS. F. CONSULT WITH AN INTEGRATIVE DR ABOUT ALTERNATIVE MEDS FOR HER MEDICAL ALIMENTS IN ADDITION TO THE USE OF ACUPUNCTURE.
PSYCHOLOGICAL EVALUATION
ROBERT F. FIERSTEIN, Ph.D.
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