Initial Evaluation

Initial Evaluation Template

Identification: Sarah Jenkins, 34 yo female (DOB: 12/05/1990, MRN: 482-910-55)

Chief Complaint: "I have been feeling completely overwhelmed and down for the last two months."

History of Present Illness

Pt presents for initial evaluation of worsening depressive and anxious sx x 2 months, triggered by increased occupational stress. Reports daily depressed mood, anhedonia, fatigue, and difficulty concentrating at work. Sx are rated 7/10 in severity and impair daily functioning.

Psychiatric Review of Systems

Depressive symptoms: Depressed mood, anhedonia, low energy, poor concentration, feelings of guilt. PHQ-9: 16.

Anxiety symptoms: Excessive worry, restlessness, muscle tension. Denies panic attacks. GAD-7: 12.

Sleep: Initial and middle insomnia, averaging 5 h/night.

Appetite: Decreased, with unintentional 3 kg weight loss over 2 months.

Suicidal and homicidal ideations: Denies SI/HI, intent, or plan.

Auditory and visual hallucinations: Denies AH/VH.

Delusions/paranoia: Denies paranoia or delusions.

Manic symptoms: Denies decreased need for sleep, grandiosity, flight of ideas, or hyperactivity.

Past Psychiatric History

• Prior diagnosis: Generalized Anxiety Disorder (diagnosed age 26)
• Hospitalizations in psychiatric units: None
• Previous suicide attempts: None
• History of self harm: Denies history of NSSI
• Access to firearms: None in the home
• Psychotropic medications: Previous trial of escitalopram (Lexapro) 10 mg PO daily x 1 year in 2018 with good response; self-discontinued due to symptom resolution.
• Current psychiatrist and therapist: None; managed by PCP.
• Cures report: Reviewed on 15/10/2024; negative for controlled substances.

Family History of psychiatric/substance use history: Mother with MDD; maternal uncle with AUD.

Substance Use History

• Alcohol: Social use, 1–2 standard drinks on weekends. Denies binges or withdrawal sx.
• Cannabis: Denies
• Amphetamines: Denies
• Nicotine: Never smoker
• Other substances: Caffeine 2 cups coffee/day. Denies illicit substances.

Medical History: Hypothyroidism, mild intermittent asthma.

Medical Review of systems: Negative for fever, CP, SOB, palpitations, abdominal pain, or neurological deficits. Positive for fatigue.

Current Medications:

• levothyroxine (Synthroid) 50 mcg PO QAM
• salbutamol (albuterol, ProAir HFA) 90 mcg/actuation 2 puffs INH Q4H PRN SOB

Allergies: Penicillin (hives).

Social History

• Marital Status: Married x 5 years
• Children: 1 child, age 3 years
• Living situation: Lives in a single-family home with husband and child
• Employment: Full-time accountant
• Education: Bachelor's degree in Accounting
• Support System: Supportive spouse, close relationship with mother and sister

Objective

Mental Status Evaluation

Appearance: Well-groomed, dressed appropriately, appears stated age.

Cognition: A&Ox4, attention and concentration intact, memory grossly intact.

Speech: Normal rate, rhythm, and volume.

Mood: "Exhausted and sad."

Affect: Constricted, mood-congruent, tearful at times.

TP: Linear, logical, and goal-directed.

TC: No SI/HI, no delusions, obsessions, or phobias.

Perc: No AH/VH or illusions.

Insight/Judgment: Good/Good.

Assessment

34 yo female presenting with a 2-month history of depressed mood, insomnia, weight loss, and anxiety consistent with Major Depressive Disorder, single episode, moderate, and Generalized Anxiety Disorder. Medical causes such as thyroid dysfunction must be ruled out given hx of hypothyroidism. Low acute risk of harm to self or others.

Plan

1. Risk Assessment: Low acute risk. No SI/HI, no prior attempts, no access to firearms. Strong protective factors include supportive family and child. Safety plan reviewed; pt provided with 988 Suicide & Crisis Lifeline.
2. Status: Voluntary outpatient.
3. Diagnostics: Order CBC, CMP, TSH, free T4, vitamin D, and vitamin B12 to rule out organic etiologies.
4. Treatment: Outpatient medication management and psychotherapy.
5. Bio: Restart escitalopram (Lexapro) 10 mg PO daily (5 mg PO daily x 7 days, then increase to 10 mg PO daily). Discussed risks, benefits, and SEs including GI upset, headache, activation, and black box warning for suicidality.
6. Psychosocial: Provided referral for weekly CBT. Encouraged sleep hygiene and regular physical activity. Follow up in clinic in 4 weeks.
7. Patient's Participation in treatment plan: Pt understands and agrees with the proposed treatment plan and demonstrates capacity to consent.

Therapeutic Interventions: Supportive psychotherapy and psychoeducation regarding CBT principles; 16 minutes.

Symptoms or Challenges Discussed: Occupational burnout, sleep maintenance difficulties, and guilt regarding parenting energy levels.

Impact on the Patient's Functioning: Decreased productivity at work and social withdrawal from friends.

Specific Topics Covered: Cognitive reframing of work-related stressors, sleep hygiene protocols, and medication adherence.

Client's Response: Receptive to feedback, engaged well, expressed relief at having a structured plan.

Prognosis: Good, given strong support system, insight, and prior positive response to SSRI therapy. Low risk of acute decompensation.

Diagnosis

• Major depressive disorder, single episode, moderate (F32.1)
• Generalized anxiety disorder (F41.1)

Billing Codes

99204, 90833

Provider's Name

Dr. Marcus Vance, MD, Family Medicine Specialist