John was diagnosed with Generalized Anxiety Disorder and Major Depressive Disorder in the
past. His psychiatrist has diagnosed him, Dr. Emily Smith, to take Sertraline 50 mg daily since
January 2024. John says that he occasionally experiences side effects of the medication, such as
nausea and dizziness, but does not have any medication allergies. The last physical examination
of the patient was conducted by his primary care physician, Dr. Michael Johnson, on 10 May
2024. John is otherwise medically fit but says his mental condition is getting worse, even with
treatment.
Mental Status Examination
The mental status of John was assessed during the intake assessment. He was well dressed,
appropriate for his age, but looked anxious and made minimal eye contact. It was described that
his motor activity was retarded, which indicated that he was in a depressive mood. John did not
present with any behavioral difficulties during the assessment, and his speech was normal in
terms of volume and fluency. Subjectively, John presented as depressed and had reduced
emotional responsiveness, which are major features of major depression. According to him, he
has been experiencing initial insomnia and has also lost slight weight due to loss of appetite.
However, throughout these procedures, John's thinking was coherent and goal-directed, with no
illusions or hallucinations. His decision-making and reasoning capabilities were preserved, and
his intelligence was described to be average. John's orientation was person, place, time, and
situation.
Substance Use and Abuse
John admits to moderate use of alcohol for social purposes but states that he has never used
tobacco, illicit drugs, or abused prescription medication. He occasionally uses over-the-counter
drugs such as Ibuprofen for treatment of Headache. John does not meet the criteria of substance
use and dependence; he has never had problems with withdrawal symptoms, blackouts,
hallucinations, or severe depression connected with the use of substances.
Safety and Risk Factors
John is comfortable at home and does not feel any danger in any form. He has not been
physically, emotionally, or sexually abused. No legal issues are present, and no safety plans are
needed since they are not considered essential at this time. John's self-assessment of suicide risk
is at a moderate level, but he has no current plan to proceed with such feelings. He said that he
attempted suicide when he was in college and was hospitalized for a brief period. This history is
an important consideration in evaluating his present risk level.
