Patient Information:
Name: John Smith Age : 36 Gender : male Marital Status : married Occupation : Chief engineer Complaint : Depression, anxiety and insomnia
A Comprehensive Psychiatric Assessment:
Identification Information I. The patient, a married 36-year old male, presents with depression, insomnia, and anxiety. The patient is an engineer who lives with his family, including two children and his wife. Patient appears well-fed and groomed. He appears alert, oriented, and aware of time, location, and person.
II. Principal complaint: Patient reports feeling depressed, with feelings of hopelessness and despair. He reports feeling anxiety symptoms, such as worry, fear and nervousness. In addition, the patient has reported having trouble falling and staying sleep, affecting his ability to function.
III. Histories of the Present Illness The patient states that his symptoms began about three months after being passed over for a job promotion. He says that since then he’s been depressed, worried, and anxious. It has affected his family and work life. He says he is having difficulty falling and staying asleep. He feels tired during the day and has low energy.
IV. Past Psychiatric Experience: No prior psychiatric experience or hospitalizations are reported by the patient. He does not have any past history of suicidal and homicidal thoughts.
No significant history of illness or present medical conditions is reported by the patient.
VI. Substance abuse: the patient admits to drinking alcohol at weekends, but denies ever having used illicit drugs or substances.
VII. Family Psychiatric history: The patient mentions that his sister and mother have both suffered from depression.
VIII. Mental Status Examination: The patient’s affect is sad and his mood is depressed. His feelings of hopelessness and thoughts about worthlessness are reported. He is able to think clearly and with a goal in mind. He is not hallucinating or having delusions. Both his memory and attention remain intact. He has trouble falling and staying asleep. This is affecting both his family and work life.
IX. Diagnosis: This patient has been diagnosed with insomnia, anxiety disorders, and major depression.
X. Treatment plan: For depression and anxiety, the patient begins taking fluoxetine at a dose of 20 mg per day. Also, he is given zolpidem (10 mg) at night for insomnia. Psychotherapy is recommended to help the patient address symptoms and develop better coping mechanisms.
Presenting Cases
John Smith, 36, is a husband and father of two who came to see us with depression, insomnia, and anxiety. Patient reports feeling depression symptoms, such as sadness, worthlessness and hopelessness. He reports feeling anxiety as well, with symptoms such as fear, worry and nervousness. In addition, the patient has reported having trouble falling and staying sleep, which is affecting his general functioning.
John’s insomnia was confirmed by a psychiatric evaluation. He also had a diagnosis of major depression, anxiety, and generalized disorder. No prior hospitalizations or mental health history are known to him. Suicidal and homicidal ideas have never occurred. John denies a history of drug or alcohol abuse but admits to occasional weekend drinking. His mother and his sister have both suffered from depression.
John began taking fluoxetine daily at a dose of 20mg for anxiety and depression as part of his prescribed treatment. John was prescribed zolpidem at night 10mg for insomnia. Referral was made to psychotherapy for the patient’s symptoms, and improving his coping techniques.
John has a set of common symptoms including anxiety, depression and insomnia. We hope that a treatment plan including psychotherapy and medication will improve John’s symptoms.
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