Compose a written comprehensive psychotherapy evaluation of a patient you have seen in the clinic.
Patient Demographics
Chief Complaint
Mr. Smith presents with a chief complaint of anxiety and depression. He reports feeling anxious and stressed all the time, and he has been having trouble sleeping. He also reports feeling down and unmotivated, and he has lost interest in activities that he used to enjoy.
History of Present Illness
Mr. Smith’s symptoms began about 6 months ago. He was working on a particularly challenging project at work, and he started to feel overwhelmed and stressed. He began having trouble sleeping, and he started to feel down and unmotivated. He also started to avoid social activities, and he would often cancel plans with friends and family.
Mr. Smith’s symptoms have gradually worsened over the past 6 months. He is now having trouble concentrating at work, and he is making careless mistakes. He is also having trouble controlling his emotions, and he has been getting into arguments with his coworkers and his family.
Past Psychiatric History
Mr. Smith has no prior history of psychiatric treatment. He has never been diagnosed with a mental illness, and he has never been prescribed medication for a mental health condition.
Past Medical History
Mr. Smith has no significant past medical history. He is in good physical health, and he does not have any chronic medical conditions.
Social History
Mr. Smith is single and lives alone. He has no children. He has a close group of friends, but he has been avoiding them since his symptoms began. He is employed as a software engineer at a large tech company. He enjoys playing video games and watching movies.
Mental Status Examination
Mr. Smith is a well-groomed and well-dressed man in his early 30s. He is cooperative and polite. He is oriented to time, place, and person. His mood is anxious and depressed. His affect is congruent with his mood. His thought process is linear and goal-directed. His speech is fluent and coherent. His memory is intact. His concentration is impaired. His insight is fair. His judgment is impaired.
Diagnosis
Mr. Smith is diagnosed with generalized anxiety disorder and major depressive disorder.
Treatment Plan
Mr. Smith will be started on a course of cognitive-behavioral therapy (CBT) and medication. CBT is a type of psychotherapy that helps people to identify and change negative thought patterns and behaviors. Medication will be used to help to manage Mr. Smith’s anxiety and depression symptoms.
Prognosis
The prognosis for Mr. Smith is good. With treatment, he is expected to experience significant improvement in his symptoms. He is likely to be able to return to work and to resume his social activities.
Recommendations
Mr. Smith is recommended to continue with psychotherapy and medication. He is also recommended to join a support group for people with anxiety and depression. He is encouraged to continue to exercise and to eat a healthy diet. He is also encouraged to get enough sleep.
Follow-Up Plan
Mr. Smith will be seen in 4 weeks for a follow-up appointment. At that time, his progress will be reviewed, and his treatment plan may be adjusted as needed.
