Anxiety/Depression Symptoms

HISTORY:

 Anxious and depressed  mood for ‍  days 

Stressors: ‍ ‍changes at workend of a relationshiphealth issues

‍feeling sad

‍anxiety

‍loss of interest

‍difficulty concentrating

‍feeling overwhelmed

‍withdrawal from social supports

‍insomnia

‍hypersomnia

‍decreased performance at work/school

‍loss of appetite

‍impulsive or risky behaviors

‍suicidal thoughts

‍hallucinations

Severity: ‍mildmoderateseveredebilitating, ‍causingwithout causing significant distress

Negative impact on: ‍daily activitiessocial lifeworkfamilypersonal relationships

Reaction to stressors is  more intense  than would normally be expected

Treatments tried: ‍none, ‍effectiveineffective

Past psychiatric history: ‍none

Family psychiatric history: ‍none



Social history:

Smoking: ‍neversmokerformer smoker, ‍ pack-years

Alcohol: ‍nonesociallyexcessive, ‍ drinks per ‍dayweek

Recreational drugs: ‍none ‍cannabis, ‍IVDU

Caffeine: ‍ per day



EXAM:

Mental Status:

Appearance:  well-dressed , ‍well-groomed, ‍goodpoor eye contact, appears ‍age-appropriate

Behavior:  cooperative 

Psychomotor activity:  normal 

Speech:  clear , ‍slowrapid, ‍monotonoustalkative

Mood:  euthymic , ‍anxious, ‍

Affect: ‍euthymic,  reactive , ‍full range,  appropriate  to situation, ‍congruent with mood

Thought process:  organized , ‍coherentincoherent, ‍logicalillogical, ‍

Thought content: ‍normalpreoccupationshopelessness,  delusions ,  no suicidal ideations ,  no homicidal ideations 

Perception: ‍normal,  no hallucinations ,  no illusions 

Cognition:  alert , oriented to ‍3 spheres, attention ‍intactdistractible, memory ‍intactimpaired

Judgment:  good 

Insight:  good  into condition



ASSESSMENT:

 Adjustment disorder  ‍likelysuspectedpossible

DDx: ‍



PLAN:

- Psychoeducation about mental condition

- Stress management techniques

- Regular exercise

- Sleep hygiene

- Avoidance of alcohol and drugs

- ‍Antidepressants

- ‍Sedatives

- ‍Atypical antipsychotics

- Referral to psychologist

- Referral to social worker

- Referral to psychiatrist

- Leave of absence from work for ‍  days 

- Follow-up in ‍ ‍weeksmonths with ‍mePCP

- Return before if condition worsen or if new symptoms develop such as suicidal thoughts