psych

Patient is a 49 year old female with a past psychiatric history significant for depression and anxiety, originally diagnosed at age 22, who presents today for psychiatric evaluation due to recurrence of symptoms over the past six months. Patient reports that following her initial diagnosis she was treated with sertraline for approximately eight years, with good response. She eventually discontinued the medication and was able to manage her symptoms through coping skills learned during individual psychotherapy. Patient reports in 2014 she moved to the United States and the transition to a new country was emotionally challenging, causing  worsening mood and anxiety during that time which led her to seek psychiatric treatment again in 2016. She recalls being treated with  venlafaxine and possibly a low-dose of Abilify, which she reports was beneficial. After several years of stability she discontinued medication and has been managing without the need of pharmacologic treatment. Over the past six months, however patient reports gradual return of the symptoms. She attributes part of the worsening mood to increased stress and burnout related to her work as a social worker at a dialysis clinic.  Patient endorses, increased incidents and episodes of sadness,  low mood, low motivation, poor concentration, excessive worry, restlessness, feelings of fear, and apprehension, and increased appetite. She describes feeling mentally exhausted and overwhelmed by her workload. Patient states that her husband and mother have encouraged her to seek psychiatric evaluation after noticing changes in her mood and behavior.  Patient reports decreased motivation and diminished ability to experience excitement about normally enjoyable activities. She states "my family and I take trips every year and I have planned a trip to Europe for spring break, but I have noticed that I'm not happy or excited about it like I should be instead I feel like I'm dragging the preparation for the trip".  Patient reports taking Benadryl at night for her allergies, but also finding it helpful for sleep endorsing approximately eight hours of sleep per night. Patient reports some fluctuations in appetite, some days snacking more than others. At this time, patient denies visual and auditory hallucinations, as well as suicidal and homicidal ideation. They voiced reason to live. Patient also denies anger, irritability, risky, or self injurious behavior. 

Protective factors include family, friends, and religion. Patient reports symptoms interfere with work, learning, social interactions, family, and adaptation to daily life. Patient denies regular use of illegal drugs, cigarette smoking, or alcohol.

PsychHx

The patient's past psychiatric history was remarkable for outpatient treatment of depression and anxiety. There was no history of hospitalizations. The patient described a history of passive death wishes in the past, no plan or intent to hurt self. No suicide attempts.