NR 546 Week 5 Case study
Subjective Objective
The client is a 29-year-old, Latino single male Physical Examination:
referred by his primary care provider for a
Height: 67″, weight: 200 lb.
psychiatric evaluation at an outpatient clinic.
General: Well-nourished male appears stated age
Client’s Chief Complaints:
Mental status exam:
“I think I might be depressed.”
Appearance: appropriate dress for age and situation, well
History of Present Illness nourished, eye contact poor, slumped posture
The client reports increasingly depressive Alertness and Orientation: alert, fully oriented to
symptoms with onset 3 months ago. He is person‚ place‚ time‚ and situation,
experiencing stress related to being unemployed, Behavior: cooperative
financial strain and needing to sell his home quickly
because he cannot afford the mortgage. He reports Speech: soft, flat
depressed mood, low energy, low motivation, Mood: depressed
anhedonia, poor concentration, loneliness, low self-
esteem, hopelessness, and decreased appetite with Affect: constricted, congruent with stated mood
12 lb. weight loss over the past month. He reports
Thought Process: logical‚ linear
difficulty falling and staying asleep due to anxiety
and restlessness, difficulty making decisions and Thought content: Self-defeating thoughts, endorses thoughts
self-isolation. He endorses anxiety related to the suggestive of low self-worth. No thoughts of suicide‚ self-harm‚ or
stressors reported above, as manifested by passive death wish
restlessness, worry, and muscle tension. He reports
Perceptions: No evidence of psychosis, not responding to internal
that his current mental state is impeding his ability
stimuli, reports auditory hallucinations.
to apply for new employment and prepare his
home for the impending sale. Memory: Recent and remote WNL
Past psychiatric history: no previous history, this is Judgement/Insight: Insight is fair, Judgement is fair
the client’s first contact with a mental health
provider. Attention and observed intellectual functioning: Attention intact
for purpose of assessment. Able to follow questioning.
Past Medical History: childhood asthma, does
Fund of knowledge: Good general fund of knowledge and
not use inhaler.
vocabulary
Family History
Musculoskeletal: normal gait
• Father is alive and well.
• Mother is alive, has anxiety “all her life”
• One brother aged 24, alive and well
Social History
• Lives alone
• single
• does not have any friends
, • alcohol use 1-2 times/week.
• no marijuana or illicit drug use
• attended one year of college.
Trauma history: Client reports was bullied in
middle school due to difficulty learning English.
No nightmares or flashbacks.
Review of Systems
• appetite diminished, weight loss 12 lbs.
• sleeps 5-6 hours at night, difficulty
falling asleep with frequent night
waking.
• No headache
• No palpitations, tremors
Allergies: NKDA, allergic to grass, perennial trees,
dust mites, and cockroaches.
Primary diagnosis: Major Depressive Disorder, single episode, moderate with anxious distress (F32.1)
Subjective Objective
The client is a 29-year-old, Latino single male Physical Examination:
referred by his primary care provider for a
Height: 67″, weight: 200 lb.
psychiatric evaluation at an outpatient clinic.
General: Well-nourished male appears stated age
Client’s Chief Complaints:
Mental status exam:
“I think I might be depressed.”
Appearance: appropriate dress for age and situation, well
History of Present Illness nourished, eye contact poor, slumped posture
The client reports increasingly depressive Alertness and Orientation: alert, fully oriented to
symptoms with onset 3 months ago. He is person‚ place‚ time‚ and situation,
experiencing stress related to being unemployed, Behavior: cooperative
financial strain and needing to sell his home quickly
because he cannot afford the mortgage. He reports Speech: soft, flat
depressed mood, low energy, low motivation, Mood: depressed
anhedonia, poor concentration, loneliness, low self-
esteem, hopelessness, and decreased appetite with Affect: constricted, congruent with stated mood
12 lb. weight loss over the past month. He reports
Thought Process: logical‚ linear
difficulty falling and staying asleep due to anxiety
and restlessness, difficulty making decisions and Thought content: Self-defeating thoughts, endorses thoughts
self-isolation. He endorses anxiety related to the suggestive of low self-worth. No thoughts of suicide‚ self-harm‚ or
stressors reported above, as manifested by passive death wish
restlessness, worry, and muscle tension. He reports
Perceptions: No evidence of psychosis, not responding to internal
that his current mental state is impeding his ability
stimuli, reports auditory hallucinations.
to apply for new employment and prepare his
home for the impending sale. Memory: Recent and remote WNL
Past psychiatric history: no previous history, this is Judgement/Insight: Insight is fair, Judgement is fair
the client’s first contact with a mental health
provider. Attention and observed intellectual functioning: Attention intact
for purpose of assessment. Able to follow questioning.
Past Medical History: childhood asthma, does
Fund of knowledge: Good general fund of knowledge and
not use inhaler.
vocabulary
Family History
Musculoskeletal: normal gait
• Father is alive and well.
• Mother is alive, has anxiety “all her life”
• One brother aged 24, alive and well
Social History
• Lives alone
• single
• does not have any friends
, • alcohol use 1-2 times/week.
• no marijuana or illicit drug use
• attended one year of college.
Trauma history: Client reports was bullied in
middle school due to difficulty learning English.
No nightmares or flashbacks.
Review of Systems
• appetite diminished, weight loss 12 lbs.
• sleeps 5-6 hours at night, difficulty
falling asleep with frequent night
waking.
• No headache
• No palpitations, tremors
Allergies: NKDA, allergic to grass, perennial trees,
dust mites, and cockroaches.
Primary diagnosis: Major Depressive Disorder, single episode, moderate with anxious distress (F32.1)
