Biopsychosocial (BPS) Assessment Notes

Biopsychosocial Assessment: Biological Factors: - The patient, a 45-year-old male, presents with hypertension and type 2 diabetes, managed with metformin and lisinopril. He reports occasional headaches and fatigue. His medical history includes a cholecystectomy performed in 2015. - Current medications include metformin, lisinopril, and atorvastatin. He also takes a daily multivitamin. - The patient has a known allergy to penicillin. Psychological Factors: - The patient reports experiencing anxiety and mild depression, with a history of cognitive-behavioral therapy. He denies any suicidal ideation. - He is currently prescribed sertraline for anxiety and depression. - There is no history of psychiatric hospitalizations. Social Factors: - The patient lives with his spouse and two children in a suburban area. He reports a supportive family environment. - He works as an accountant and is currently employed full-time. - The patient completed a bachelor's degree in finance. - He denies any legal issues or history of incarceration. - The patient reports occasional alcohol use, approximately 2-3 drinks per week, and denies tobacco or illicit drug use. Assessment: - The patient presents with well-managed hypertension and diabetes, alongside anxiety and mild depression. Social support is strong, and occupational status is stable. - Diagnostic impression includes generalized anxiety disorder and major depressive disorder, mild. Plan: - Continue current medications: metformin, lisinopril, atorvastatin, and sertraline. - Recommend continuation of cognitive-behavioral therapy sessions. - Referral to a dietitian for nutritional counseling to support diabetes management. - Follow-up appointment scheduled in 4 weeks to monitor blood pressure, glucose levels, and mental health status.