CMSA psychiatry clerk

Difficulty obtaining history: Patient was initially reluctant to engage, but became more forthcoming after reassurance. Reliability of information: Information is considered reliable as the patient was able to provide consistent details. Demographics: Name: John Smith Age: 35 Language: English Marital Status: Married Children: Two children, ages 5 and 7. Employment status: Employed as a software engineer. - Disability grant / Pension / Medical boarding: N/A Accommodation: Lives in a rented apartment with his family. Religion: Christian Handedness: Right-handed Context of assessment: Outpatient Route of referral: Referred by GP. MHCA status: Not applicable. Presenting Complaint: Verbatim presenting concern: "I've been feeling down and anxious for the past few months." History of Presenting Complaint: Onset: Symptoms began approximately 4 months ago. Precipitant/s: Increased workload and financial stress. Temporal relation to precipitant/s: Symptoms worsened following a job promotion. Duration: Symptoms have persisted for 4 months. Evolution: Symptoms have gradually worsened over time. Aggravating/Relieving factors: Symptoms are worse in the mornings and improve slightly in the evenings. Socialising with friends helps. Associated symptoms: - Medical: No significant medical symptoms. - Psychiatric (DSM screening): Reports low mood, anxiety, difficulty sleeping, and loss of interest in activities. Response to treatment: Has not received any prior treatment. Systematic enquiry: Mood cluster, Anxiety cluster. Past Psychiatric History: First episode: No prior episodes. First point of contact: GP. Diagnoses: Major Depressive Disorder, Generalised Anxiety Disorder. Episode history: N/A Admissions: N/A Past pharmacological, psychological, and social interventions: N/A ECT: N/A Rehabilitation: N/A Adherence: N/A Past suicide attempts/self-harm: Denies any suicidal ideation or self-harm. Past Medical and Surgical History: Neurological: No neurological history. Other Medical: No significant medical history. Gynae/Obstetric: N/A Surgeries: Appendectomy at age 10. Allergies: No known allergies. Past/Current treatments: N/A Past Drug and Alcohol History: Cigarettes: Never smoked. Alcohol: Drinks alcohol socially, approximately 2-3 units per week. Other drugs: Denies illicit drug use. Caffeine: Drinks 2-3 cups of coffee per day. OTC medications: Occasional use of ibuprofen for headaches. Forensic History: Cautions/Charges/Convictions: No forensic history. Sentences: N/A Pending cases: N/A Antisocial behaviour screen: N/A Family History: Genogram summary: Father with a history of depression. Mother with anxiety. One sibling, no known mental health issues. Deaths: Paternal grandfather died of a heart attack at age 70. Medical illness: Father has hypertension. Psychiatric illness: Father with depression, Mother with anxiety. Relationships and attachment quality: Good relationships with family members. Personal History: Developmental: Normal developmental milestones. Educational: Completed university. Occupational: Employed as a software engineer. Psychosexual/Relationships: Married, in a stable relationship. Current Social Circumstances: Stable housing, employed, good social support. Premorbid Personality: Generally optimistic and outgoing, enjoys socialising and outdoor activities.