History of Present Illness
Presenting problems/chief complaint:
The client, a 32-year-old female, is seeking treatment due to persistent feelings of anxiety and depression that began approximately six months ago. She reports that the symptoms have become more severe over the past two months, affecting her daily functioning. "I feel overwhelmed and unable to cope," she states.
Current Symptoms:
The client reports experiencing anxiety, low mood, fatigue, and difficulty concentrating. Observations include a flat affect and tearfulness during the session.
Area(s) of functional impairment:
The client's symptoms are impacting her work performance, as she struggles to meet deadlines and maintain focus. She also reports withdrawing from social activities and experiencing strained relationships with family members.
History of mental health treatment/substance use treatment:
The client has a history of attending therapy sessions for anxiety during her college years but has not engaged in any treatment since then. No substance use treatment history is reported.
Family history of mental health/substance use including treatment, if any:
The client's mother has a history of depression and was treated with medication and therapy. No substance use issues are reported in the family.
Psychosocial:
The client is currently employed as a marketing manager but is concerned about job security due to her declining performance. She has no legal issues but is experiencing financial stress due to student loans.
Interpersonal/family information:
The client describes her relationship with her family as supportive but distant. She has a few close friends but has been avoiding social interactions. She is single and not currently in a romantic relationship.
Current living situation:
The client lives alone in a rented apartment. She reports feeling isolated and occasionally worries about the risk of losing her housing due to financial instability.
Cultural considerations:
The client identifies as Hispanic and mentions that cultural stigma around mental health has made it difficult for her to seek help. She feels pressure to appear strong and self-reliant.
Trauma and/or Abuse History:
The client reports experiencing emotional abuse from a previous partner, which contributes to her current anxiety. No other trauma is noted.
Client Strengths:
The client is articulate and demonstrates insight into her condition. She has a supportive network of friends and family and is motivated to improve her mental health.
Substance Use
Current Substance Use:
N/A
Previous substance use:
None
Health history and/or current medical conditions:
No relevant past or present health concerns reported.
Current medications:
Sertraline, 50mg, prescribed for depression and anxiety.
Primary Care Physician: Dr. Emily Carter, (555) 123-4567, last routine exam on 1 September 2024.
Psychiatrist/NP: None Reported
Risk Assessment
1. Columbia Suicide Severity Rating Scale (C-SSRS):
N/A
2. Client denies any current or past suicidal ideation.
MSE (Mental Status Exam)
1. Mood: Depressed
2. Appearance: Well-groomed
3. Thought Process: Linear, goal-directed
4. Rapport: Cooperative
5. Thought Content/Perceptions: Normal
6. Behavior: Normal
7. Cognition: Normal, Fully Oriented
8. Speech: Normal
9. Insight: Good
10. Affect: Constricted
11. Judgment: Fair
Clinical Summary
The client presents with symptoms consistent with generalized anxiety disorder and major depressive disorder, impacting her occupational and social functioning. Treatment is needed to address these symptoms and improve her quality of life.
Diagnosis
Generalized Anxiety Disorder (GAD), Major Depressive Disorder (MDD)
