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Granta, Kevin (prefers “KG”), DOB: 2/11/71
1. Identifying Data: KG presents as a 39-year-old, single Caucasian male who resides alone in the family home at 122 Belt Line Road, and who is here for a psychiatric evaluation and update. He is of average height, short blonde hair, hygiene and grooming within normal limits, slightly overweight. KG has a long history of severe depression, social phobia and multiple hospitalizations. He is a transfer from Dr. Lynch (retired).
2. Chief Complaint: KG claims that the Paxil he takes for his anxiety complaint has ceased to work effectively. He began this process with Dr. Lynch prior to transfer of case.
3. History of Present Illness: KG states that although he was always described as a “nervous, mopey kid” his mental health issues came to the fore during college, which also coincided with alcohol abuse/dependence and drug experimentation. KG showed early aptitude for music and after college was guitarist/singer for rock band whose “label showcase” performance coincided with his first mental health breakdown and hospitalization. KG consequently discontinued live performance but records “ambient” music under his own initials for a small record company. This is the only paid work KG has done since – he receives SSD/SSI in addition to any proceeds from recording. KG has been hospitalized two other times – once brought by ambulance after slashing wrists, once for overdose of medication which KG calls an “accident”.
4. Current Medications: KG has been taking Paxil for the past 5½ years for anxiety. He is also currently taking Abilify, Wellbutrin for depression and Simvastatin for high cholesterol.
5. Family Psychiatric History: None noted. KG referred to an aunt who always had a problem with “nerves” but had no official diagnosis that he knew of.
6. Lethality Assessment: KG has been hospitalized for severe depression three times, twice due to lethality concerns. KG expresses no lethality currently, but mood has been much lower than usual due to what he believes is diminishing returns from Paxil.
7. Strengths: No current ideation, willingness to get help, musical talent/vocation, support groups through internet.
8. Liabilities: Single, male, living alone, partially unemployed, chronic, isolates, history of lethality/hospitalizations.
9. Substance Abuse History: KG smokes an average of 4 cigarettes per day. KG claims to have had issues utilizing alcohol for self-medication in the past to the point of blackouts, but currently drinks 1 beer per day/3-4 times per week. KG has experimented with marijuana, hallucinogens and amphetamines in the past, but found that they interacted with his mental illness in negative ways so discontinued use.
10. Allergies: No known drug allergies.
11. Past Medical History: Denies any serious illness/operations.
12. Developmental and Social History/Personal History: KG reports childhood as “unremarkable” before age of 14 when father was killed in industrial accident. Mother did not remarry. Mother died when KG was 32. He has lived in the family home all his life with exception of college and short period thereafter. KG has never married and is childless. He has carried on several relationships with women but claims that all “ended badly”. KG has not been in a serious relationship since prior to his mother’s death. His social circle is nearly non-existent aside from the internet and various phone contacts. KG expresses some regret over this but also appears to have accepted the situation as being a logical consequence of his mental illness. He did not respond to overtures to broaden social contacts or to begin attending support groups/continued day treatment available through clinic.
13. Impression: KG is a pleasant man of young middle age. His orientation x3 is intact, memory good, appearance and grooming within normal limits. Displayed some agitation and negative viewpoint but was unerringly polite. Displays very little hope/motivation to change but despite this no current lethality concerns. No hallucinations/delusions; reality testing intact.
Axis I: 296.33, Major Depressive Disorder, Recurrent ; 300.23, Social Phobia
Axis II: R/O Personality Disorder NOS
Axis III: Denies.
Axis IV: Psychosocial stressors and environmental stressors, mild.
Axis V: GAF 55.
1. Change in meds to Comaxyn, 125mg 2x daily. Discontinue Paxil.
2. Other meds remain the same.
3. Review labs with client, blood work within normal limits. No side effects noted from the previous medication; will monitor new medication for any changes at first appointment.
4. Desired outcome is to maintain stability and prevent relapse, promote quality of life and social functioning.
5. Advised client about appointment in 1 month or to call sooner if he has any mood changes, side effects, problems or concerns.
Dr. William Hennig
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