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