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
... [Show More] 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 selfesteem, 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 [Show Less]