Initial Psychiatric Evaluation – Clinical Notes Format

Initial Psychiatric Evaluation – Clinical Notes Format
Your Name
Subject and Section
Professor’s Name
March 13, 2023
* IDENTIFYING DATA:
Patient is a 32-year-old male currently residing in an apartment downtown.
* CHIEF COMPLAINT:
“I have been feeling really down and can’t seem to shake it off. I don’t want to do anything anymore.”
* REFERRAL SOURCE:
Self-referral.
* HISTORY OF PRESENT ILLNESS:
During the initial evaluation, the patient reported additional symptoms that may be indicative of a more complex presentation. The patient described feeling anxious and on edge, experiencing frequent bouts of worry and feeling tense. He reported that these symptoms have been present for several years but have intensified in the past two months. Additionally, the patient reported experiencing physical symptoms such as headaches, stomach aches, and muscle tension, which he attributes to his anxiety.
The patient also reported difficulty concentrating and forgetfulness, which has impacted his ability to perform well at work. He described feeling overwhelmed and unable to keep up with his responsibilities, leading to increased stress and frustration. The patient also reported a recent increase in alcohol use to cope with his symptoms for the past two weeks.
* RISK ASSESSMENT:
Do you have thoughts of harming yourself?

NO

Do you have a plan for how you would harm yourself?

NO

Have you attempted to harm yourself in the past?

NO

Have any relatives committed suicide?

NO

Do you have thoughts of harming someone else?

NO

Have you assaulted or threatened anyone recently?

NO

Have you ever been in trouble because of your temper/violence?

NO

Does drinking/drugging ever lead you to become violent?

NO

Do you own a gun or a lethal weapon?

NO

Have you ever considered/planned harming yourself or others with this gun or other lethal weapon?

N/A

* PAST PSYCHIATRIC HISTORY:
Patient reports no prior psychiatric hospitalizations but had symptoms of depression that were not severe enough to seek medical help.
* PAST MEDICAL HISTORY:
Patient reports a history of hypertension and hyperlipidemia. He is taking medication for both conditions and reports being compliant with treatment.
* DEVELOPMENTAL HISTORY:
Not applicable.
* FAMILY STRUCTURE:
Patient is married and has two children.
* SUBSTANCE USE HISTORY:
Patient reports social alcohol use but denies drug use.
* FAMILY PSYCHIATRIC HISTORY AND GENETICS:
Patient reports a family history of depression in his father.
* SOCIAL HISTORY:
Patient is married and has two children. He works full-time as an accountant.
* COMPREHENSIVE MENTAL STATUS EXAM:
* Appearance: well-groomed, casually dressed
* Behavior: cooperative, fidgety
* Mood: depressed
* Affect: blunted
* Thought Process: coherent
* Thought Content: denies suicidal/homicidal ideation, no psychotic symptoms
* Perception: no perceptual disturbance
* Cognition: alert and oriented to person, place, and time; memory and concentration intact
* Insight/Ju...