Describe the HPI and clinical impression for the client.

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HPI (History Of Present Illness), for the client, is: She is a 41-year old woman who complained to her physician about sleep problems, lack of energy, being overwhelmed with life, and a general feeling of unmotivation. Her symptoms have been present for approximately 6 months. They are worsening in the last few weeks. She has also had mild episodes of depression in her adulthood, but never sought help.

This information may give the impression that the patient is suffering from a major depression disorder. However, more assessment will need to be done in order to confirm the diagnosis and determine what treatment plan would be best. A thorough physical exam should be conducted along with laboratory testing to rule out any physiological causes for the patient’s symptoms such as hormonal imbalances or deficiencies in essential vitamins or minerals that could contribute to her mood changes. In addition, it is important to complete a mental assessment that includes an evaluation of the patient’s past medical and family histories as well current stressors. The screening tool should be administered, if appropriate. All these factors can help to determine an accurate diagnosis, and a management plan that is appropriate.