Subjective

Objective

The client is a 29-year-old, Latino single male referred by his primary care provider for a psychiatric evaluation at an outpatient clinic.

Client’s Chief Complaints:

“I think I might be depressed.”

History of Present Illness

The client reports increasingly depressive symptoms with onset 3 months ago. He is experiencing stress related to being unemployed, financial strain and needing to sell his home quickly because he cannot afford the mortgage. He reports depressed mood, low energy, low motivation, anhedonia, poor concentration, loneliness, low self- esteem, hopelessness, and decreased appetite with 12 lb. weight loss over the past month. He reports difficulty falling and staying asleep due to anxiety and restlessness, difficulty making decisions and self-isolation. He endorses anxiety related to the stressors reported above, as manifested by restlessness, worry, and muscle tension. He reports that his current mental state is impeding his ability to apply for new employment and prepare his home for the impending sale.

Past psychiatric history: no previous history, this is the client’s first contact with a mental health provider.

Past Medical History: childhood asthma, does not use inhaler.

Family History

•         Father is alive and well.

•         Mother is alive, has anxiety “all her life”

•         One brother aged 24, alive and well

Social History

•         Lives alone

•         single

•         does not have any friends

Physical Examination:

Height: 67″, weight: 200 lb.

General: Well-nourished male appears stated age

Mental status exam:

Appearance: appropriate dress for age and situation, well nourished, eye contact poor, slumped posture

Alertness and Orientation: alert, fully oriented to person‚ place‚ time‚ and situation,

Behavior: cooperative Speech: soft, flat Mood: depressed

Affect: constricted, congruent with stated mood Thought Process: logical‚ linear

Thought content: Self-defeating thoughts, endorses thoughts suggestive of low self-worth. No thoughts of suicide‚ self-harm‚ or passive death wish

Perceptions: No evidence of psychosis, not responding to internal stimuli, reports auditory hallucinations.

Memory: Recent and remote WNL Judgement/Insight: Insight is fair, Judgement is fair

Attention and observed intellectual functioning: Attention intact for purpose of assessment. Able to follow questioning.

Fund of knowledge: Good general fund of knowledge and vocabulary

Musculoskeletal: normal gait

•         alcohol use 1-2 times/week.

•         no marijuana or illicit drug use

•         attended one year of college.

Trauma history: Client reports was bullied in middle school due to difficulty learning English. No nightmares or flashbacks.

Review of Systems

•      appetite diminished, weight loss 12 lbs.

•      sleeps 5-6 hours at night, difficulty falling asleep with frequent night waking.

•      No headache

•      No palpitations, tremors

Allergies: NKDA, allergic to grass, perennial trees, dust mites, and cockroaches.