IMPRESSION:
Axis I: Dementia with delusions, probable.
Axis II: Deferred.
Axis III:
1. Weakness.
2. History of cerebrovascular accident.
3. History of diabetes mellitus.
Axis IV: Extreme.
Axis V: Global assessment of functioning 35.
ASSESSMENT:
Axis I: Bipolar disorder, not otherwise specified; history of polysubstance dependence.
Axis II: Deferred.
Axis III: Atypical chest pain and hypertension.
Axis IV: Stressors multiple, severe, related to primary support group.
Axis V: Global assessment functioning of 45.
ASSESSMENT:
Axis I: Opioid withdrawal, opioid dependence, adjustment disorder with depressed mood.
Axis II: Deferred.
Axis III: Crohn disease, pulmonary emboli.
Axis IV: Stressors related to the patient’s medical condition.
Axis V: Global assessment of functioning of 45.
ASSESSMENT:
Axis I: Rule out adjustment reaction, not otherwise specified, secondary to medical complications (309.9).
Axis II: Deferred.
Axis III: See above.
Axis IV: Current psychosocial stressors include prolonged hospitalization.
Axis V: Current global assessment of functioning equals 75-80.
DIAGNOSTIC IMPRESSION:
Axis I: Major depression, recurrent type.
Axis II: Neurological factors affecting physical condition, histrionic personality.
Axis III:
1. Atypical chest pain.
2. Gastroesophageal reflux disease.
3. Hypertension.
Axis IV: Husband’s illness.
Axis V: Global assessment of functioning 44 upon evaluation, past year 55.
DIAGNOSTIC IMPRESSION:
Axis I: Bipolar mood disorder with psychotic features, rule out schizoaffective disorder.
Axis II: Borderline personality traits.
Axis III:
1. Hypertension.
2. Gastroesophageal reflux disease.
Axis IV: Unsatisfactory living condition.
Axis V: Global assessment of functioning 42 upon evaluation, past year 45.
DIAGNOSTIC IMPRESSION:
AXIS I: 294.9. Cognitive disorder, not otherwise specified; rule out adjustment reaction, not otherwise specified.
AXIS II: Deferred.
AXIS III: See above.
AXIS IV: Current psychosocial stressors include being away from primary support, having limited access to health care and prior substance abuse.
AXIS V: Current global assessment of functioning equals 60, past year 80.
DIAGNOSTIC IMPRESSION:
Axis I: 296.33. Major depressive disorder, recurrent, without psychotic features.
Axis II: Borderline intellectual functioning and borderline personality features, provisional.
Axis III: None reported.
Axis IV: Problems related to his legal status and social environment.
Axis V: Global assessment of functioning currently equals 30. Highest past year equals unknown.
DIAGNOSES:
Axis I:
1. Generalized anxiety disorder, currently in remission with medications.
2. Depressive disorder, in remission.
3. History of posttraumatic stress disorder, also in good remission.
4. Opioid dependence, in forced remission.
Axis II: Antisocial personality disorder.
Axis III: Physical examination not done.
Axis IV: Legal problems.
Axis V: Past global assessment of functioning of 70. Current global assessment of functioning of 70.
DIAGNOSES:
Axis I:
1. Schizoaffective disorder, bipolar type.
2. Alcohol dependence, in a controlled environment.
3. Polysubstance dependence, in a controlled environment.
4. Nicotine dependence.
Axis II: Antisocial personality disorder.
Axis III: Hyperlipidemia.
Axis IV: Limited support system.
Axis V: Global assessment of functioning of 60.
DIAGNOSTIC ASSESSMENT:
Axis I:
1. Adult attention deficit hyperactivity disorder.
2. Polysubstance dependence, currently in remission in a controlled environment.
3. Substance-induced mood disorder.
4. Alcohol dependence syndrome, currently in remission in a controlled environment.
Axis II: Antisocial personality disorder.
Axis III: Human immunodeficiency virus positive.
Axis IV: Psychosocial stressors, severe. Lack of social skills, poor social support, chronic mental illness.
Axis V: Current global assessment of functioning of 60-65.
DIAGNOSES:
Axis I: Schizophrenia, paranoid type, with chronic delusions and partial refractoriness to treatment.
Axis II: None.
Axis III: Hypertension and residual chronic obstructive pulmonary disease.
Axis IV: Limited support system.
Axis V: Global assessment of functioning of 51-55.
DIAGNOSTIC IMPRESSION:
Axis I:
1. History of agoraphobia, in remission.
2. Substance abuse, mixed type, per history.
Axis II: Antisocial personality disorder.
Axis III: Splenectomy.
Axis IV: Legal problems.
Axis V: Global assessment of functioning of 70.
DIAGNOSES:
Axis I: Mood disorder, not otherwise specified; rule out generalized anxiety disorder with agoraphobia; rule out major depressive disorder; rule out schizophreniform disorder; rule out substance-induced mood disorder.
Axis II: Deferred.
Axis III: Possible history of anticholinergic delirium and dextromethorphan toxicity.
Axis IV: Severe problems with primary and social support, occupation, finances and education.
Axis V: Current global assessment of functioning is 30 to 35.
DIAGNOSES:
AXIS I: Chronic schizophrenia, undifferentiated type, posttraumatic stress disorder, impulse control disorder, not otherwise specified.
AXIS II: Mild mental retardation.
AXIS III: History of seizure disorder and diabetes mellitus.
AXIS IV: Moderate.
AXIS V: Global assessment of functioning is 40.
DIAGNOSES:
AXIS I:
1. Major depression, recurrent, severe with intermittent stress related visual hallucinations, symptoms in remission.
2. Rule out bipolar disorder.
3. Medication noncompliance.
AXIS II: Narcissistic features.
AXIS III:
1. Hypertension, stable.
2. Gastroesophageal reflux disease, stable.
AXIS IV: Moderate.
AXIS V: Global assessment of functioning 65 on discharge.
DIAGNOSES:
AXIS I:
1. Bipolar disorder, mixed features, symptoms in remission.
2. Attention deficit hyperactivity disorder by history, symptoms in remission.
3. Rule out intermittent explosive disorder.
AXIS II: No diagnosis.
AXIS III:
1. Hypercholesterolemia, stable on discharge.
2. Increased bilirubin, stable on discharge.
AXIS IV: Mild.
AXIS V: Global assessment of functioning 65 on discharge.
DISCHARGE DIAGNOSIS:
AXIS I:
1. Bipolar disorder, depressed, symptoms in remission.
2. Attention deficit disorder, symptoms in remission.
AXIS II: Deferred.
AXIS III: Asthma, stable.
AXIS IV: Moderate history of noncompliance with medications.
AXIS V: Global assessment of functioning 65 on discharge.
INITIAL IMPRESSION:
Axis I:
1. 300.4. Dysthymic disorder, early onset. Rule out 309.81, posttraumatic stress disorder.
2. Polysubstance dependence.
Axis II: Deferred.
Axis III: No diagnosis.
Axis IV: Psychosocial stressors, severe.
Axis V: Current global assessment of functioning of 60 to 70, past year 60 to 70.
DIAGNOSTICS:
Axis I:
1. Obsessive-compulsive disorder (primarily obsession).
2. Generalized anxiety disorder.
Axis II: Borderline personality disorder with history of self-mutilation, which is stable at this time.
Axis III: Medical history.
Axis IV: Stressors severe due to past psychiatric history and personality pathology as well as anxiety related symptoms.
Axis V: Global assessment of functioning of 51-55.
