Case #5

NR 546 Week 5 Case Study

09.24 MWS

Subjective Objective

The client M.L. is a 34-year-old, Hispanic

female being seen for a psychiatric evaluation

at an outpatient clinic.

Client’s Chief Complaints:

“I feel sad. I can't seem to enjoy anything

anymore, and it's affecting my sleep and

appetite.”

History of Present Illness

M.L. reports a six-month history of persistent

sadness, loss of interest in activities, and

constant feelings of anxiety. She has trouble

sleeping, poor appetite, and frequent fatigue.

M.L. also mentions having trouble

concentrating and feeling overwhelmed by

daily tasks.

She denies any thoughts of self-harm or suicide

but admits to feelings of hopelessness about her

future.

Past psychiatric history: Denies any history of

previous psychiatric diagnoses or treatment for

depression. However, she acknowledges a

family history of depression, with her sister and

mother having been diagnosed and treated for

the condition; this is the client’s first contact

with a mental health provider.

Past Medical History: none

Family History

• Father is alive and well.

• Mother is alive, has depression and

being treated.

• One sister 36, with depression

Social History

• Lives alone in an apartment.

Physical Examination:

Height: 5’7″, weight: 140 lb.

General: Well-nourished female appears stated age

Mental status exam:

Appearance: Appropriate dress for age and situation, well

nourished, poor eye contact, slumped posture

Alertness and Orientation: Alert, fully oriented to person‚

place‚ time‚ and situation,

Behavior: Cooperative

Speech: Soft, flat

Mood: Depressed

Affect: Constricted, congruent with stated mood

Thought Process: Logical‚ linear

Thought content: Expresses feelings of worthlessness and

hopelessness. Denies thoughts of suicide‚ self-harm‚ or

passive death wish. Denies homicidal ideation.

Perceptions: Denies experiencing any perceptual

disturbances, such as auditory or visual hallucinations. No

evidence of psychosis, not responding to internal stimuli.

Memory: Recent and remote WNL

Judgement/Insight: Insight is fair, Judgement is fair

Attention and observed intellectual functioning: Attention

intact for the purpose of assessment. Able to follow

questioning.

Fund of knowledge: Good general fund of knowledge and

vocabulary

Musculoskeletal: Normal gait

NR 546 Week 5 Case Study

09.24 MWS

• Works as a customer service

representative.

• High school graduate with some college

education.

• Smokes socially, 1-2 cigarettes per

week.

• Drinks alcohol occasionally, 1-2 times

per month.

• No current recreational drug use.

• Few close friends and limited social

interactions outside of work.

Trauma history:

• Reports emotional abuse during

childhood from father

• Denies history of physical or sexual

abuse

Review of Systems

• General: Fatigue and low energy levels.

• Cardiovascular: No chest pain or

palpitations.

• Respiratory: Occasional shortness of

breath related to asthma.

• Gastrointestinal: Poor appetite and

occasional nausea.

• Musculoskeletal: No joint pain or

muscle aches.

• Neurological: No headaches or seizures.

• Sleep: Difficulty falling asleep and

staying asleep, averaging 4-5 hours per

night

Allergies: NKDA

Primary diagnosis: Major Depressive Disorder, single episode,

moderate with anxious distress (F32.1)