Case Formulation and Treatment Plan

· HPI: S.Y is 19 -year-old African-American female self-referred to manage feelings of depression. Client reports having “bouts” of depression since 9th grade but has been experiencing more depression and suicidal thoughts since college. Patient reports that she has always sought validation and feels that she puts a lot of pressure on herself. Stated depression began during 9the grade but has been increasingly more since college. Client reports an increase in symptoms within the last two weeks. Also reports having panic attacks within the last month and she always struggled with social anxiety without any specific reasons. No history of hospitalizations or medication treatment. Client reports that she will restrict her eating three/four times a week. Client reports that “she focused on changes in my routine”. Denied any history of trauma. Client reports that her father struggles with depression and her brother may have some mental health challenges as well. Client reports that she has seasonal allergies and asthma in which she uses an inhaler to manage. Albuterol- Asthma. Patient diagnosed today with F41.1 Generalized Anxiety Disorder F33.2 Major Depressive Disorder, Recurrent episode, Severe and Acute Stress Disorder. Client was born and raised in Baltimore. She reports that her mother is from Baltimore and her father is from North Carolina. Parents are married and client has four siblings. Client reports that she has an older sister and an older brother both in their 40s and both reside in North Carolina. Client has two sisters who lives with her. Client reports having a good relationship with her younger two siblings and her parents. Client also has a good relationship with her, maternal grandparents. She reports that her paternal grandfather is deceased and her paternal grandmother resides in an assisted living facility.

Social History: Client reports having a good relationship with her younger siblings and she has friends. Client is attending and in her 4th year at University of Baltimore majoring in criminal justice with a minor in psychology and victims studies. Client wants to become a victims advocate or social worker in the correctional setting. Client is employed part-time for the college in the student community and inclusion department as an admin. assistant

· Substance Current Use: Denies

· Medical History: Asthma since birth.

· Current Medications: Albuterol pump as needed

· Medication trials: : Wellbutrin SR 75mg daily, Vistaril 25mg daily.

· Allergies: None

· Reproductive Hx: Sexually active

ROS:

· GENERAL: No fever, chills, chest tightness, weakness headache, chills, , body aches or weight loss.

· HEENT: Eye : Denies visual loss, blurred vision, double vision. Ears: Denies hearing loss. Throat: Denies congestion or sore throat.

· SKIN: Denies itching or presence of rashes

· CARDIOVASCULAR: Denies chest pain, pressure or discomfort, palpitations.

· RESPIRATORY: Denies shortness of breathing, wheezing, chest tightness, pain while breathing.

· GASTROINTESTINAL: Reported good appetite and. Denies nausea, vomiting or diarrhea. Denies abdominal pain.

· GENITOURINARY:  Denies burning with urination, hesitancy or urgency. Denies changes in urine color or odor

· NEUROLOGICAL: Denies headache, dizziness, syncope. Denies seizures,

· MUSCULOSKELETAL: Denies joint or muscle pain or weakness, Denies pain with walking or moving;

· HEMATOLOGIC: Denies bleeding. No history of anemia. Denies any blood transfusion

· LYMPHATICS: No enlarged nodes

Objective:

Diagnostic results:

Assessment:

Mental Status Examination:

Diagnostic Impression:

Reflections: