Psych Intake

Identification: John Doe, 45, Male Chief Complaint: "I have been feeling extremely anxious and unable to sleep for the past few weeks." History of Present Illness: John Doe reports a gradual onset of anxiety symptoms over the past month, with increasing severity. He describes difficulty sleeping, feeling restless, and experiencing frequent panic attacks. Psychiatric review of systems: Depressive symptoms: John reports feeling hopeless and having a lack of interest in activities he once enjoyed. Anxiety symptoms: He experiences constant worry, restlessness, and panic attacks. Sleep: John has difficulty falling asleep and staying asleep, often waking up multiple times during the night. Suicidal and homicidal ideations: John denies any suicidal or homicidal ideations or plans. Auditory and visual hallucinations: He denies experiencing any hallucinations. Delusions/paranoia: John denies any delusional or paranoid thinking. Manic symptoms: He denies any manic or hypomanic symptoms. PTSD: John reports flashbacks and nightmares related to a past traumatic event. OCD: He denies any obsessive-compulsive symptoms. Past Psychiatric History: Prior diagnosis: Generalized Anxiety Disorder, Major Depressive Disorder Hospitalizations in psychiatric units: None Previous suicide attempts: None History of self harm: None Access to firearms: No access to firearms Psychotropic medications: Currently taking Sertraline 50mg daily Current psychiatrist and therapist: Dr. Emily Smith, Therapist: Sarah Johnson Cures report: Available Family History of psychiatric/substance use history: John's mother had a history of depression and his father struggled with alcohol use disorder. Legal History: No history of legal issues. Trauma History: John experienced emotional abuse during childhood, which was not reported to legal authorities. Substance Use History: Participation in outpatient or inpatient levels of care for substance use: None Alcohol: Occasional social drinking Cannabis: Denies use Amphetamines: Denies use Nicotine: Smokes half a pack of cigarettes daily Other substances: Denies use Medical History: Reports a history of migraines and denies any head trauma or seizures. Medical Review of Systems: No significant findings. Current Medications: Sertraline 50mg daily Historical Medications: Previously tried Fluoxetine, experienced nausea as a side effect Drug Allergies: None known Allergies: None known Social History: Marital Status: Married Children: Two children, ages 10 and 15 Living situation: Lives with spouse and children Employment: Works as a software engineer Education: Bachelor's degree in Computer Science Support System: Strong support from family and friends Objective: Mental Status Evaluation: Appearance: Well-groomed, casually dressed Cognition: Alert and oriented to person, place, and time Speech: Normal rate and volume Mood: Anxious Affect: Congruent with mood TP: Linear and goal-directed TC: No evidence of delusions or hallucinations Perc: No perceptual disturbances noted Insight/Judgment: Good insight and judgment Assessment: John presents with symptoms of anxiety and depression, consistent with Generalized Anxiety Disorder and Major Depressive Disorder. Plan: 1. Risk Assessment: Low risk for self-harm or harm to others, protective factors include strong family support. 2. Status: Voluntary 3. Diagnostics: No additional tests required at this time 4. Treatment: 5. Bio: Continue Sertraline 50mg daily, discuss potential side effects and benefits 6. Psychosocial: Cognitive Behavioral Therapy (CBT) sessions weekly, safety planning 7. Patient's Participation in treatment plan: John is willing to engage in therapy and medication management Therapeutic Interventions: CBT, 60-minute session Symptoms or Challenges Discussed: Anxiety management, sleep hygiene Impact on the Patient's Functioning: Anxiety significantly impacts John's work performance and social interactions Specific Topics Covered: Coping strategies, relaxation techniques Client's Response: John is receptive to therapy and actively participates Prognosis: Good, with continued treatment and support Diagnosis: Generalized Anxiety Disorder (F41.1) Major Depressive Disorder, Recurrent, Moderate (F33.1) Billing Codes: 99205, 90837 Provider's name: Nurse Jane Thompson