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WEEK 4 ASSIGNMENT: COMPREHENSIVE PSYCHIATRIC EVALUATION
NOTE And PATIENT CASE PRESENTATION, PART 2
Judith Asika
College of Nursing-PMHNP, Walden University
PRAC 6645: Psychotherapy with Multiple Modalities Practicum
Dr. Oyewole, Daniel
03/23/2025
, 2
Subjective:
Client Background: Pt’s Name: L.H Age: 20 Race: Spanish Gender: Female
Diagnosis: ADHD with Focus Issue.
CC (chief complaint): “I am sad, feeling disconnected from reality, struggling with depression,
crying, and lacking purpose.”
HPI: L.H., a 20-year-old Spanish female, attended an individual counseling session. She was
diagnosed with ADHD and takes Adderall inconsistently, finding the medication ineffective
when compared with her sister's combination of Adderall and antidepressants. The counselor
recommended that she consult her psychiatrist regarding medication issues, which she agreed to.
She feels her medication isn't working due to her non-compliance with the regimen. She reports
sadness, crying, feeling disconnected from reality, and struggling with depression and lack of
purpose. She also mentioned issues with her sister and fear of vulnerability after her breakup,
along with frustration over her mom’s criticism and lack of acknowledgment of her dad’s efforts.
The counselor suggested focusing on forgiveness, emotional balance, and moving forward,
which She agreed to try. A follow-up session is scheduled for next week.
Past Psychiatric History:
• Psychiatric History: The client is diagnosed with ADHD and previously seen by a
psychiatrist. She is currently taking Adderall but is not compliant with the medication
Regimen. She reports that Adderall is not effective when compared with their sister, who
takes her antidepressants.
© 2022 Walden University Page 2 of 16
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• General Statement: Denied weight loss, fever, chills, weakness, fatigue, or malaise.
• Caregivers (if applicable): NA
• Hospitalizations: NA
• Medication trials: Adderall presently: Dosage not indicated
• Psychotherapy: Yes, effective; currently enrolled in Individual Counseling Session
• Previous Psychiatric Diagnosis: ADHD with Focus Issue.
• Pertinent Substance Use: Alcohol
• Suicidal or Homicidal behaviors: No Si/HI presently. No hx of Self-Harm behaviors.
Substance Current Use and History:
• Hx of current Use of caffeine, nicotine, illicit substance use: Binges alcohol as a coping
mechanism to deal with her situation. Daily amount not reported.
• Types of Use: Inhales, Snorts, IV, etc: NA
• Hx Use of Withdrawal Complications: Tremors, Delirium Tremens, or seizures: NA
Psychosocial History: The client is of Mexican descent, and her family moved to the U.S. They
live in Texas. Her parents raised her, and she still lives with them. She is single and has no
children. She has three siblings and has a graduate degree. She enjoys posting on social media
and has worked in this area. She has no legal history. The client reports childhood trauma from
neglect by her parents, her sister's abuse, and verbal abuse from an ex-boyfriend. There are no
concerns about violence in her home or surroundings.
Family Psychiatric/Substance Use History:
© 2022 Walden University Page 3 of 16
WEEK 4 ASSIGNMENT: COMPREHENSIVE PSYCHIATRIC EVALUATION
NOTE And PATIENT CASE PRESENTATION, PART 2
Judith Asika
College of Nursing-PMHNP, Walden University
PRAC 6645: Psychotherapy with Multiple Modalities Practicum
Dr. Oyewole, Daniel
03/23/2025
, 2
Subjective:
Client Background: Pt’s Name: L.H Age: 20 Race: Spanish Gender: Female
Diagnosis: ADHD with Focus Issue.
CC (chief complaint): “I am sad, feeling disconnected from reality, struggling with depression,
crying, and lacking purpose.”
HPI: L.H., a 20-year-old Spanish female, attended an individual counseling session. She was
diagnosed with ADHD and takes Adderall inconsistently, finding the medication ineffective
when compared with her sister's combination of Adderall and antidepressants. The counselor
recommended that she consult her psychiatrist regarding medication issues, which she agreed to.
She feels her medication isn't working due to her non-compliance with the regimen. She reports
sadness, crying, feeling disconnected from reality, and struggling with depression and lack of
purpose. She also mentioned issues with her sister and fear of vulnerability after her breakup,
along with frustration over her mom’s criticism and lack of acknowledgment of her dad’s efforts.
The counselor suggested focusing on forgiveness, emotional balance, and moving forward,
which She agreed to try. A follow-up session is scheduled for next week.
Past Psychiatric History:
• Psychiatric History: The client is diagnosed with ADHD and previously seen by a
psychiatrist. She is currently taking Adderall but is not compliant with the medication
Regimen. She reports that Adderall is not effective when compared with their sister, who
takes her antidepressants.
© 2022 Walden University Page 2 of 16
, 3
• General Statement: Denied weight loss, fever, chills, weakness, fatigue, or malaise.
• Caregivers (if applicable): NA
• Hospitalizations: NA
• Medication trials: Adderall presently: Dosage not indicated
• Psychotherapy: Yes, effective; currently enrolled in Individual Counseling Session
• Previous Psychiatric Diagnosis: ADHD with Focus Issue.
• Pertinent Substance Use: Alcohol
• Suicidal or Homicidal behaviors: No Si/HI presently. No hx of Self-Harm behaviors.
Substance Current Use and History:
• Hx of current Use of caffeine, nicotine, illicit substance use: Binges alcohol as a coping
mechanism to deal with her situation. Daily amount not reported.
• Types of Use: Inhales, Snorts, IV, etc: NA
• Hx Use of Withdrawal Complications: Tremors, Delirium Tremens, or seizures: NA
Psychosocial History: The client is of Mexican descent, and her family moved to the U.S. They
live in Texas. Her parents raised her, and she still lives with them. She is single and has no
children. She has three siblings and has a graduate degree. She enjoys posting on social media
and has worked in this area. She has no legal history. The client reports childhood trauma from
neglect by her parents, her sister's abuse, and verbal abuse from an ex-boyfriend. There are no
concerns about violence in her home or surroundings.
Family Psychiatric/Substance Use History:
© 2022 Walden University Page 3 of 16
