Psychiatric Evaluation Demographic Information

Rosa Rodriguez

163 E. 174th street Bronx NY 10463

Phone (Home/Cell): *** Phone (Work): ***

Date of Birth: 11/11/1954

Social Security #: 050-44-5555

Guardianship (for children and adults when applicable): Not Applicable

Marital Status: Widowed

Family Members: Patient has three sons and one sister.

Roberto Rodriguez, 25, M, Son

Juan Rodriguez, 27, M, Son

Steven Rodriguez, 22, M, Son

Felicia Rivera, 57, F, Sister

Employer: Retired

Occupation: Retired Nurse

Emergency Contact Information

Felicia Rivera

Phone ***

Relationship to Patient: Sister

Current Providers: Medicare and Aetna

Primary Medical Practitioner: Dr. Yomaris Pena

Phone ***

Patient does not give permission to contact provider.

Other Behavior Health Specialists or Consultants Specialist: None

Presenting Problem (include onset, duration, intensity)

Patient has been experiencing depressive symptoms and potentially suicidal thoughts. Depressive symptoms first appeared when her husband died around 7 years ago. They only transformed into depression when she received the diagnosis that she is HIV +. She has been depressed for over a year and within the last few months it has grown more intense with her desire to stop taking medication that treats her HIV.

Precipitating Event (why treatment now):

The reason she was diagnosed with HIV is that she slept with a man, whom she met after five years of mourning her husband's death, who is HIV +. She had unprotected sex with the man and within over a year, he distanced himself from her. She did not know why he would act this way until her friend told her he had received an HIV diagnosis in January of 2011. Friend suggested patient should go get tested. She decided to go and they discovered she has HIV as well. She felt angry and feels angry with herself more, for letting herself have unprotected sex. She feels almost defeated now and does not want to continue after such a grave mistake.

Target Symptoms:

Frequency/Duration Degree of Impairment

Symptom #1: Angry and Sad all the time due to being diagnosed with HIV

Symptom #2: Patient describes lack of interest in hobbies or connecting with friends and family members. Shows tendency towards isolation since HIV diagnosis.

Patient has no other symptoms related to depression such as insomnia, mood swings, or suicidal tendencies.

IV. Mental Status (circle appropriate items)

Orientation: Person

Affect: Appropriate, Sad, and Angry, Flat

Mood: Depressed, Angry (Patient has described feeling sad and angry for some time, especially after HIV Diagnosis

Thought Content: Patient does not seem to have any obsessions or compulsions.

Describe: Patient has no eating disorder or engages in activities that would show any obsessions. She appears to feel depressive symptoms brought on from a painful and life changing event.

Delusions (specify and comment): Patient reported no delusions or history of delusions.

Hallucinations (specify and comment): Patient reported no hallucinations or history of hallucinations. Thought Processes:

Patients thought process seems logical as she sad and angry because she is sick with a disease that could kill her and she blames herself for it for having unprotected sex.

Patient is coherent as she can recite the names of the last three presidents.

Goals are non-existent as patient expressed no desire to continue taking medication or becoming healthy again.

Patient name: Rosa Rodriguez

Speech: Normal

Motor: Normal

Intellect: Average

Insight: Present

Judgment: Intact

Control: Adequate

Impaired Memory: No impaired memory

Concentration: Intact

Attention: Intact

Behavior: Appropriate

Describe: Patient does not engage in odd or alarming behavior. She has a strong social circle. She comes to the assessment clean and well groomed.

Details/additional comments: Patient speaks normally. She does not recount any other symptoms other than anger and sadness and possibility of refusing to take her medication. She is humorous. She is communicative. There is no history or stated desire to commit suicide. She can recount names of presidents and does not appear to have any notable memory loss.

V. Risk Assessment

Suicidal Ideation? None, Attempt Passive

Although patient does not express wanting to commit suicide, she does desire to stop taking her medications. As an HIV patient, if she stops taking her medication, she could die from complications. She also has type 2 diabetes and high blood pressure (hypertension). Stopping all medications may kill her within a short period.

Homicidal Ideation None

Patient does not express any desire to kill anyone.

VI. Medical/Behavioral Health History

Patient takes Metformin for type II diabetes and a beta-blocker, Atenolol, for high blood pressure (hypertension). She has no history of mental illness or depression. Although patient has stated she has always been sad and angry, it only culminated within the last few years out of grief, loss, and the HIV diagnosis.

Allergies (adverse reactions to medications/food/etc.)

She has no known allergies to food or latex. Is allergic to Sulfa Drugs.

Medications Is the member currently prescribed BH (Behavioral Health)...

Is member taking other medications (prescribed or over the counter) or supplements? Yes (if yes please list and indicate why).
Atenolol 100 mg for high blood pressure (hypertension) at bedtime, Metformin 500 mg BID for type II diabetes, HAART therapy for HIV.

Past Psychiatric History (Mental Health and Chemical Dependency):

Patient has not shown any mental health issues like hallucinations or false logic. Patient has no documented history of mental illness or suicide attempts.

Psychiatric Hospitalizations:

There has been no history of psychiatric hospitalization.

Prior Outpatient Therapy (include previous practitioners, dates of treatment, previous treatment interventions, response to treatment interventions (including responses to medications), and the source(s) of clinical data collected):

Patient Rosa has had no behavioral health medications, or outpatient treatment. This initial assessment is the first documented time she sought treatment for any mental health issues.

Patient name: Rosa Rodriguez

Results of recent lab tests and consultation reports (For physicians only and only where applicable): Suggested lab tests to rule out any malnutrition or other medical illnesses that could add to formation of depression in patient:

Complete blood cell (CBC) count

Thyroid-stimulating hormone (TSH)

Rapid plasma reagin (RPR)

Vitamin B-12

Blood urea nitrogen (BUN) and creatinine

Liver function tests (LFTs)

Electrolytes, including calcium, phosphate, and magnesium levels

Blood alcohol level

Blood and urine toxicology screen

Dexamethasone suppression test (Cushing disease, but also positive in depression)

Cosyntropin (ACTH) stimulation test (Addison disease)__ Family Mental Health or Chemical Dependency Arterial blood gas (ABG)

Family History: Patient has three sons and a sister. She is a widow whose husband died roughly 7 years ago. Goes to church weekly.

VII. Psychosocial Information: Grief over loss of husband. Grief over HIV diagnosis.

Support Systems: Sons and sister as well as some friends provide the support system.

School/Work Life: She is a retired nurse. Worked as a nurse for two and a half decades. Had prior schooling, completing an RN Associate degree.

Legal History: Denies ever having any legal/criminal record or arrest record.

VIII. Substance Abuse History (complete for all patients age 12 and over)

No history of substance abuse either documented or described.

Risk Factors:

No history of abuse cited. No documented suicide ideation. No eating disorder described. No hallucinations. Normal speech has been observed. No hallucinations, compulsions, or obsessions.

Diagnostic Impression: 296.21 Mild. Patient appears to have depression without psychotic features. Has not suggested any suicide attempts. Depression seems mild as she still attends church weekly and speaks with her relatives.

Axis I:

Nature of Stressors: The major source of stress appears to be her health as she is HIV positive. Another previous stressor was the death of her late husband.

Patient's name: Rosa Rodriguez

All treatment goals must be objective and measurable, with estimated timeframes for completion. The treatment plan is to be developed with the patient, and the patient's understanding of the treatment plan is to be documented in the medical record.

Treatment Goals [after each item selected, indicate outcome measures (i.e. "as evidenced by")

Reduce Risk Factors: Patient stated she might stop taking her medications. Stopping HAART therapy could have fatal consequences. Research suggests many people diagnosed with HIV experience depression and may stop taking their medication. "HIV is still a jarring enough diagnosis to plunge a patient into depression. With a chronic condition like HIV, depression can fuel additional problems, such as failure to take life-saving antiretroviral medications" (Heitz, 2014). Perhaps including family members to help administer medication may provide some relief for the patient. Adherence counseling can also prove to be beneficial as people with HIV are very likely to refuse strict adherence of drug therapies. The latest HIV drug therapies require strict and almost perfect adherence in order to provide benefits to HIV patients. "Newly emerging antiretroviral medications for HIV have been shown to be effective but require near perfect adherence to offer clinically significant benefits. There is currently great interest in deriving patient factors that may predict optimal medication adherence in HIV-positive persons" (Cruess, Minor, Antoni & Millon, 2007, p. 277).

Reduce Major Symptoms: In order to reduce major symptoms talk therapy may be beneficial. An exercise plan can prove to help not only with depression, but also improve patient's high blood pressure and insulin sensitivity, which may also play a role in her overall mental health. "Exercise helps prevent and improve a number of health problems, including high blood pressure, diabetes and arthritis. Research on anxiety, depression and exercise shows that the psychological and physical benefits of exercise can also help reduce anxiety and improve mood" (Mayoclinic.org, 2015). Behavioral medication does not seem appropriate. She already takes a lot of medication and this could interfere with her desire to adhere to taking her medication.

Decrease Functional Impairments: Things like isolating herself and keeping herself from fun activities and hobbies can and does increase likelihood of worsening depressive symptoms. Exercise…