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PSYCHIATRIC OUTPATIENT CLINIC
123 Main Street
Anywhere, US 12345-6789
Complete Evaluation: Psychiatrist
Date of Exam: 6/8/2016
Time of Exam: 5:22:37 PM
Patient Name: Little, Aimee
Patient Number: 1000010659748
History: Mrs. Little is a widowed Canadian 38 year old woman. Her chief complaint is, "I am completely miserable since
my dear husband died."
The following information was provided by:
Mrs. Little
Mrs. Little's family.
Mrs. Little describes symptoms of a depressive disorder. She reports that there is a precipitant for her depression. Mrs.
Little's current depressive symptoms are attributed to the death of an important person in her life, details are as follows:
"My husband died of cancer three months ago." Depressive symptoms began insidiously over a period of months. She
describes episodes of chronic or daily depression.
Current Symptoms: She reports that her appetite is decreased. Some weight loss has occurred. She reports a weight
loss of more than five pounds. She reports the weight change as occurring over the following timeframe: One Month.
Concentration difficulty associated with her depressive symptoms have been reported. Mrs. Little reports that her mind
often wanders. She reports "Crying Spells" or episodes. Feelings of sadness have been reported. She reports difficulty
sleeping. Insomnia is reported.
Suicidality: She denies suicidal ideas or intentions. Denial is convincing.
Prior Depressive /Manic Episodes: She reports that there have been no prior depressive episodes. Mrs. Little does
not have a history of manic or hypomanic episodes.
Severity/ Complexity: Based on the risk of morbidity without treatment and her description of interference with
functioning, severity is estimated to be moderate.
Mrs. Little has symptoms of anxiety. Anxiety symptoms have been present for months. Anxiety symptoms are occurring
daily. She reports occurrences of difficulty concentrating. Feelings of restlessness are described. Difficulty sleeping is
occurring. There is difficulty falling asleep. She describes an exaggerated startle response.
Problem Pertinent Review of Symptoms/Associated Signs and Symptoms: No obsessive, intrusive and persistent
thoughts or compulsive, ritualistic acts are reported. No hallucinations, delusions, or other symptoms of psychotic
process are reported by her.
Past Psychiatric History:
Withdrawal History:
There is no history of Mrs. Little ever having experienced withdrawal from any substance.
Psychiatric Hospitalization:
Mrs. Little has never been psychiatrically hospitalized.
Outpatient Treatment:
Mrs. Little received outpatient mental health treatment for anxiety problems. This occurred when she was in her
20's. This episode lasted for months. No medication was prescribed.