Initial Evaluation

Initial Evaluation Template: Identification: Jane Doe, 32 years old, Female Chief Complaint: "Feeling overwhelmed and constantly worried for the past six months." History of Present Illness: Ms. Doe presents with a six-month history of generalised anxiety, manifesting as persistent worry about everyday tasks, her job, and her family's well-being. She reports difficulty concentrating, muscle tension, and irritability. Symptoms are worse during periods of high work stress and have been progressively worsening, impacting her social life and sleep. She denies any specific triggers but notes a gradual escalation of her anxious feelings. Psychiatric review of systems: Depressive symptoms: Reports low mood occasionally, but denies anhedonia or suicidal ideation. States her low mood is usually a direct result of her anxiety. Anxiety symptoms: Constant, pervasive worry, difficulty controlling worry, feeling keyed up or on edge, difficulty concentrating, muscle tension, and sleep disturbance. Experiences occasional panic-like symptoms but denies full-blown panic attacks. Sleep: Difficulty falling asleep due to racing thoughts, wakes frequently throughout the night, and often feels unrefreshed in the morning. Averages 4-5 hours of fragmented sleep per night. Appetite: Reports decreased appetite due to anxiety, with occasional nausea. Has lost approximately 3 kg over the past two months. Suicidal and homicidal ideations: Denies any suicidal ideations, plans, or attempts. Denies any homicidal ideations or plans. Auditory and visual hallucinations: Denies any auditory or visual hallucinations. Delusions/paranoia: Denies any delusional or paranoid thinking. Manic symptoms: Denies elevated mood, increased energy, decreased need for sleep, or rapid speech. Past Psychiatric History: - Prior diagnosis: None prior to this presentation. - Hospitalizations in psychiatric units: Denies any psychiatric hospitalisations. - Previous suicide attempts: Denies any previous suicide attempts. - History of self harm: Denies any history of self-harm behaviours. - Access to firearms: Does not have access to firearms. - Psychotropic medications: No current or past use of psychotropic medications. - Current psychiatrist and therapist: No current mental health care providers. - Cures report: CURES report not available at this time.