My impression of uberman:
The patient arrived on time. He is alert, pleasant, and cooperative. He is well groomed and maintains good eye contact. Intelligence is above average. Insight and judgment are good. He is oriented to time, place, and person. Memory is good for immediate and recent recall of three objects. He recalls presidents Bush, Clinton, and Bush. He is able to spell the word “world” in both forward and reverse directions accurately, but with a bit of difficulty in reverse. Speech is goal-directed, coherent, and of normal rate and tone. Mood is “good,” but affect is anxious. The patient becomes more anxious with some of the questioning during the mental status examination, particularly proverb interpretation. He denies auditory or visual hallucinations. He denies suicidal or homicidal ideation. He states that the proverb, “People who live in glass houses shouldn’t throw stones” is “speaking about not being hypocritical.”
FORMULATION:
The patient is a 36-year-old Caucasian male with a long history of depression and attention deficits. Hyperactivity criteria are essentially absent. Although medications have been somewhat efficacious, he has residual symptoms that are quite troublesome.
DIAGNOSES:
AXIS I 296.32 Major depression, recurrent, moderate.
314.00 Attention-deficit hyperactivity disorder, inattentive type.
AXIS II V71.09 No diagnosis.
AXIS III History of gastroesophageal reflux disease, status post Nissen fundoplication, variable hypertension of uncertain etiology, retinal damage from the wrestling injury, chronic back pain.
AXIS IV Occupational problems, other psychosocial and environmental problems.
AXIS V Current GAF: 54. Highest in the past year: 54.
STRENGTHS:
Above average intelligence, college education, stable employment.
PROGNOSIS:
Good, if the patient follows through with appropriate treatment. Without proper treatment, the patient will likely have further substantial deterioration of psychosocial functioning.
