Behavioral Health Service (BHS) Initial Consult Note
BHS Contact: X Initial Consult-Scheduled
Referring Physician: Dr. Ngo
Reason: Depression
Primary Medical Condition(s): high blood pressure, arthritis
Screening Data: PHQ-9 score: 14/27
Medications: reviewed in chart - Celexa
Complaints/Symptoms: doesn't care if she lives, sad, lonely
Pt. is a 53 y/o woman who has been depressed for several years, is currently taking Celexa but is not certain it is helping. Pt. has difficult relationship with daughter which is a source of worry.
Trigger Event(s)/Problem Hx: started in 2008 after divorce from husband
Maintaining Factors/Barriers to Change: no money/savings, no vehicle/transportation, emotional abuse from ex-husband, still lives with ex-husband, limited social support
Prior Coping Efforts: church
Functional Status:
Work: part-time work taking care of elderly, unemployed since 2011 previously worked for a hotel doing house keeping.
Relationships: elderly woman patient cares for.
Valued Activities: walking, movies, reading, taking care of elderly people
Physical Activities: walking
Substance Use:
Caffeine: coffee 1x/day
Tobacco: none
ETOH: none
Other Drug: none
Mental Status:
Temperament on Presentation: polite, appeared sad
Affect: Flat, depressed
Sleep: decreased, 3-4 hours a night. Difficulty falling asleep
Energy Level: decreased
Psychomotor: WNL
Speech: WNL
Appetite: WNL
Attention/Concentration: distractibility
Thoughts: negative/worried related to daughter
Pain Level: 7/10 (emotional)
Risk Assessment:
SI/HI:yes- doesn't care if she lives
S/H Plans:No
Prior S/H Attempts:yes x1 - 1987, hospitalized for 3 days
Hopelessness/Helplessnessyes
Substance Abuse:No
Domestic Violence:yes- none currently / 1997 at Serene Harbor for 4 months
Other Self-Injurious:No
Protective FactorsNo
Strengths/Positive Actions Taken: goes to church
Tx Targets: depression, sleeping, worry/stress
Initial Dx: ICD-9 296.3 Major Depression –recurrent/ongoing
Motivation to Change:
8/10 Readiness
10/10 Recognized Importance
6/10 Confidence in Ability to Change
Plan:
Pt. will talk to son about helping around the house.
Pt. will walk 30 min 2-3x/week.
Pt. will do deep breathing or lemon squeezing when feeling stressed.
Pt. will not use electronic or watch TV one hour before bed, will read instead.
Interventions Utilized:
X Psychoeducation- depression
X Handouts- vicious cycle of depression, improving your feeling, coping skills
X Sleep Hygiene- not using electronics
X Behavioral Activation- walking
X Pleasurable Activities- reading, walking
Will refer to Women's Center for longer-term treatment but will see her here for 4-5 visits.
Will discuss possibility of a new antidepressant and possible sleep aid with Dr. Ngo
Pt. is scheduled for f/u in 2 weeks.