Presenting concerns
Client reports feeling he has 'depression, anxiety, everything,' but is also unsure of the specific nature of his problem.
History of present illness
Client, Shahid, presents with self-reported 'depression' and 'anxiety.' He reports experiencing 'a lot of stress,' which he links to some issues with financial investments. Key symptoms include significantly reduced sleep ('very little') and a marked decrease in his ability to focus at work. Despite these difficulties, the client reports he is still able to enjoy time with his family. Onset, duration, and prior episodes were not elicited in this session.
Past psychiatric history
(None elicited)
Family history
(Not elicited)
Social history
Client is a married man who is currently employed. He reports being able to enjoy time with his family. Further details regarding education, living situation, and substance use were not elicited.
Mental status exam
PLACEHOLDER. Speech was of normal rate and tone. Client reported a mood of 'depression' and 'stress.' Affect appeared congruent. Thought process was logical and goal-directed. Thought content was notable for preoccupations with financial stress and his emotional state. There was no evidence of psychosis or perceptual disturbance. Insight is fair, as he recognizes his distress and sought help, though he is uncertain of its specific etiology. Judgment appears intact.
Working hypothesis
Client's symptoms of low mood, anxiety, poor sleep, and difficulty concentrating in the context of financial stressors are suggestive of an Adjustment Disorder with Mixed Anxiety and Depressed Mood. Rule out Major Depressive Disorder and Generalized Anxiety Disorder pending further assessment of symptom duration and severity.
The Pass 3 initial-assessment brief expands this into a differential with citations.
Immediate plan
(Not elicited)