Problem:
Subjective Chief Complaint: "I can't stop thinking, and I can't sleep at night." History of Present Illness: 45 y/o male presents with overactive thoughts, a racing mind, irritability, and insomnia that has progressively worsened over the past few years. He has trouble maintaining sleep and reports no significant physical health issues. Psychiatric History: The patient has no previous diagnosis of anxiety or depression but expresses feelings of restlessness and irritability. Medical History: He has no chronic medical conditions and no history of hospitalization. Medication Adherence and Side Effects: The patient has not been on any psychiatric medications prior to this consultation and denies any side effects from medications. Social History: He is employed full-time in retail, lives alone, and spends time socially with friends on weekends. Family History: The patient's father has a history of depression, and an older brother struggles with alcohol dependence. Substance Use History: The patient consumes alcohol, typically 4-6 beers on Friday and Saturday nights, but denies use of illicit drugs. Risk Assessment: The patient denies any suicidal or self-harm thoughts, demonstrating no immediate risk. Need Assignment Help?