The patient is a 23 years old female who presents with a chief complaint of depression, for which she recently started
therapy. She reports that her therapist conducted an intake about two weeks ago and recommended contacting a
psychiatric provider for medication management. The patient describes feeling sad, depressed, and unhappy, with
the past two weeks being particularly difficult performing her job. She reports a lack of motivation, leading to missed
work and a general sense of being "down." The patient also experiences stress and anxiety, which contribute to her
avoidance of activities and a tendency to shut down. She reported that this is not the first time she has felt this way,
as her symptoms began around the start of the COVID-19 pandemic. She reported that she briefly tried therapy two
years ago but did not continue with treatment or see a psychiatrist at that time.
The patient reports a decreased appetite, often having to force herself to eat. She stated her energy levels vary, with
some days being better than others, but overall, she feels exhausted and struggles to complete tasks. She has lost
interest in activities she previously enjoyed, such as reading, and feels more hopeless than hopeful. The patient also
reports poor concentration and difficulty focusing. She denies any current SI,HI,AH,VH and delusional thoughts.
PsychHx
Denies HX of psych hospitalization
Endorsed SI with no plan nor attempts
Denies HX of Acting out Behavior
Denies HX of Assault
PMHx
Comments: Denies
PSHx
Comments: Tongue-Clip surgery at age 4
PsychFHx
Mother and Father has Depression and Anxiety
Sister has Depression and Anxiety, other family members and other siblings also has Depression, Anxiety and ADHD
Sister has HX of Alcohol Usage
Mother has SUD issues
PsychSHx
She was born in Colombia MD
She has four siblings
She is the oldest child of five siblings, mother raised her, She describes a challenging upbringing, with an absent
father and a mother who worked multiple jobs, leading to the patient taking on a parental role for her younger siblings
Stepfather abused her and her siblings physically and emotionally
Highest level of education, High school Diploma, currently enrolled in college
Employed part time
Single and she has no children
sexual orientation-She stated she is interested in everybody
Gender Identity-Female
HX of Marijuana usage, she smokes every day, she gets it from the dispensary-she stated it helps somewhat with
Anxiety , and also to calm down
Denies other illicit drug usage
Occasionally drinks Alcohol
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