Psychiatric Intake

Identification: Elena Rostova, 34 yo female (DOB: 12/08/1991, MRN: 492-817-33)

Chief Complaint: "I haven't been able to get out of bed for the past month, and I just feel completely numb."

History of Present Illness

• 34 yo F presenting for initial psychiatric evaluation of worsening depressive and anxious sxs. Onset ~3 months ago following a job layoff, with severe exacerbation over the past 4 weeks. Reports daily depressed mood, severe anhedonia, anergia, guilt, and impaired concentration. Experiencing daily generalized worry regarding finances with occasional panic attacks (palpitations, SOB, diaphoresis, lasting 15 mins, 2x/wk). Denies clear precipitant for panic episodes.

Psychiatric review of systems

• Depressive symptoms: Depressed mood most of the day, nearly every day; marked anhedonia; 5 kg weight loss over 2 months due to decreased appetite; psychomotor retardation; severe fatigue; feelings of worthlessness; impaired concentration.
• Anxiety symptoms: Excessive, uncontrollable worry regarding finances and future; restlessness; muscle tension; episodic panic attacks 2x/week with autonomic arousal.
• Sleep: Initial and middle insomnia, averaging 4–5 hrs of fragmented sleep per night.
• Suicidal and homicidal ideations: Endorses passive SI ("Sometimes I wish I just wouldn't wake up"), denies active SI, intent, or plan. Denies HI.
• Auditory and visual hallucinations: Denies AH/VH.
• Delusions/paranoia: Denies paranoia or delusions.
• Manic symptoms: Denies history of decreased need for sleep, grandiosity, flight of ideas, or hyperactivity.
• PTSD: Flashbacks and nightmares related to childhood physical abuse, triggered by loud noises or yelling; hypervigilance in public spaces.
• OCD: Denies obsessions or compulsions.

Past Psychiatric History

• Prior diagnosis: MDD, GAD.
• Hospitalizations in psychiatric units: 1 inpatient admission in 04/2018 at Northwestern Memorial Hospital for 5 days due to severe depression and active SI; completed a 4-week PHP following discharge. Denies history of ECT or TMS.
• Previous suicide attempts: 1 interrupted attempt in 04/2018 (prepared to overdose on OTC analgesics, roommate intervened).
• History of self harm: History of superficial cutting on bilateral forearms in late adolescence; last episode >10 years ago.
• Access to firearms: Denies access to firearms or weapons in the home.
• Psychotropic medications: Previously trialed on sertraline and bupropion; currently on escitalopram.
• Current psychiatrist and therapist: Previously managed by PCP (Dr. M. Vance); sees therapist Sarah Jenkins, LCSW biweekly.
• Cures report: CURES/PDMP report reviewed today; negative for controlled substances over the past 12 months.

Family History of psychiatric/substance use history: Mother with MDD (responded well to fluoxetine). Maternal uncle with AUD and completed suicide at age 45.

Legal History: Denies history of arrests, probation, or pending legal issues.

Trauma History: History of childhood physical and emotional abuse by biological father between ages 7 and 12; CPS was involved and father was removed from the home, though no formal criminal charges were pursued.

Substance Use History

• Participation in outpatient or inpatient levels of care for substance use: Denies history of inpatient or outpatient substance use treatment.
• Alcohol: Drinks 1–2 glasses of wine on weekends; denies blackouts, tolerance, or withdrawal.
• Cannabis: Smokes cannabis flower 1–2x/month socially for sleep; last use 3 weeks ago.
• Amphetamines: Denies lifetime use.
• Nicotine: Former vaper (nicotine), quit 2 years ago; previously 1 pod every 3 days for 3 years.
• Other substances: Denies lifetime use of cocaine, opioids, hallucinogens, or unprescribed benzodiazepines. 1 cup of coffee daily.

Medical History: Hypothyroidism. Denies history of concussions, LOC, seizures, or other head trauma.

Medical Review of Systems: Positive for fatigue and weight loss. Negative for fever, chest pain, palpitations (outside of panic episodes), GI distress, dysuria, or neurological deficits.

Current Medications:

• escitalopram (Lexapro®) 10 mg PO daily
• levothyroxine (Synthroid®) 50 mcg POQAM

Historical Medications:

• sertraline (Zoloft®) up to 100 mg PO daily for 8 months in 2018 (discontinued due to emotional blunting and sexual dysfunction).
• bupropion XL (Wellbutrin XL®) 150 mg PO daily for 2 weeks in 2020 (discontinued due to increased anxiety and insomnia).

Drug Allergies: Penicillin (hives).

Allergies: Seasonal pollen (rhinitis).

Social History

• Marital Status: Single, currently in a 2-year relationship with supportive partner.
• Children: None.
• Living situation: Lives in an apartment with her partner in Chicago, IL.
• Employment: Unemployed for 3 months; previously worked as a senior graphic designer.
• Education: Bachelor of Fine Arts (BFA).
• Support System: Partner, mother, and two close friends living locally.

Objective

Mental Status Evaluation

• Appearance: Well-groomed, appears stated age, dressed casually in clean clothing, mild psychomotor slowing noted.
• Cognition: Alert and oriented x4; attention and concentration intact during interview; short- and long-term memory grossly intact.
• Speech: Normal rate, low volume, flat prosody, increased latency of response.
• Mood: "Numb and exhausted."
• Affect: Constricted, dysphoric, congruent with stated mood.
• TP: Linear, logical, and goal-directed.
• TC: Positive for passive SI without intent or plan. Denies HI. Denies paranoid, grandiose, or somatic delusions.
• Perc: Denies AH, VH, or tactile hallucinations; no internal preoccupation noted.
• Insight/Judgment: Insight is good; judgment is intact.

Assessment

• 34 yo F with hx of MDD, GAD, and childhood trauma presenting with a severe recurrent depressive episode and comorbid anxiety/panic attacks precipitated by recent job loss. Symptoms cause significant functional impairment despite current treatment with escitalopram 10 mg PO daily. Passive SI is present, but chronic risk is mitigated by strong social support, future orientation, and lack of intent/plan.

Plan

• 1. Risk Assessment: Low-to-moderate acute risk. Despite hx of prior interrupted attempt (2018) and current passive SI, patient denies active intent/plan, has no access to firearms, and demonstrates good insight, strong partner support, and willingness to engage in treatment. Collaborative safety plan completed, including crisis line numbers (988) and removal of excess OTC medications by partner.
• 2. Status: Voluntary outpatient.
• 3. Diagnostics: Order CBC, CMP, TSH, Free T4, Vitamin D, and Vitamin B12 to rule out organic contributors (especially given hx of hypothyroidism).
• 4. Treatment: Optimize SSRI dosage and initiate PRN non-benzodiazepine anxiolytic; continue outpatient psychotherapy.
• 5. Bio: Increase escitalopram (Lexapro®) from 10 mg to 20 mg PO daily for depressive and anxious sxs. Start hydroxyzine pamoate (Vistaril®) 25 mg PO Q6H PRN anxiety/insomnia. Discussed risks, benefits, and SEs (GI upset, sedation, QT prolongation, rare activation/suicidality warning); patient verbalized understanding and consented.
• 6. Psychosocial: Continue biweekly CBT with current therapist (S. Jenkins, LCSW). Encouraged behavioral activation and sleep hygiene measures. Follow up in clinic in 3 weeks.
• 7. Patient's Participation in treatment plan: Patient is receptive to medication adjustments, agrees with the safety plan, and commits to getting lab work completed this week.
• Therapeutic Interventions: 20-minute supportive psychotherapy and CBT-informed cognitive restructuring incorporated into initial evaluation (conducted 30/03/2026 at 14:00 America/Chicago).
• Symptoms or Challenges Discussed: Addressed catastrophic thinking surrounding unemployment, feelings of worthlessness, and severe morning lethargy.
• Impact on the Patient's Functioning: Symptoms currently prevent patient from updating her resume, applying for jobs, and maintaining routine household chores.
• Specific Topics Covered: Cognitive distortions (all-or-nothing thinking, catastrophizing), graded task assignment for job hunting, and sleep restriction techniques.
• Client's Response: Engaged well, able to identify cognitive distortions with prompting, and agreed to set a small goal of spending 15 minutes daily on her portfolio.
• Prognosis: Fair to good, contingent on medication adherence, continued therapy, and resolution of acute psychosocial stressors. Low risk of acute decompensation requiring hospitalization at this time.

Diagnosis

• F33.2 Major depressive disorder, recurrent, severe without psychotic features
• F41.1 Generalized anxiety disorder
• F43.10 Post-traumatic stress disorder, unspecified

Billing Codes

• 99205 (New patient office visit, high MDM)
• 90833 (Psychotherapy add-on, 30 minutes)

Provider's name: Dr. Julian Vance, MD, Psychiatrist