COMPREHENSIVE PSYCHIATRIC EVALUATION NOTE

 COMPREHENSIVE PSYCHIATRIC EVALUATION NOTE
Subjective:
CC: “I am pretty tired, otherwise I am ok”.
HPI: T.M is a 27-year-old male who presented voluntarily for a psychiatric psychotherapy
session. He has a history of anxiety, poor sleep, impulsive behaviors, paranoia, depression,
irritability, anger, mood instability. He reports "manic" episodes in the back. The patient also has
a history of sadness, decreased energy, decreased motivation, decreased concentration, isolation,
and social anxiety. The patient also has a good response to the current medication regimen.
Past Psychiatric History:
? General Statement: The patient started treatment for mental health issues at a very young
age, which he did not disclose. He conveyed that he never felt the need of therapy until
recently.
? Caregivers (if applicable): The patient is considered an adult and provided consent for
this examination.
? Hospitalizations: The patient indicated a history of multiple inpatient hospitalizations.
? Medication trials: Although, admitted optimum results with many previous medications
regimen. The patient stated that he sometimes becomes non-compliant with his
medications.
? Psychotherapy or Previous Psychiatric Diagnosis: The patient was previously diagnosed
with MDD, substance abuse disorder, and adjustment disorder.
Substance Current Use and History: The patient does have a history of substance abuse and
recreational drugs. Currently uses cocaine on occasion and marijuana every day. The patient also
uses alcohol more than three times a week, mostly on the weekends.