Chief Complaint: A 25-year-old individual presents to the clinic with concerns r

Chief Complaint:
A 25-year-old individual presents to the clinic with concerns related to their sexual orientation and gender identity.
History of Present Illness:
The patient reports experiencing confusion, distress, and discomfort related to their sexual orientation and gender identity. They mention feeling unsure about their sexual orientation and whether it aligns with their assigned sex at birth. They also express a desire to explore and understand their gender identity better. The patient describes experiencing anxiety, depression, and social isolation due to these concerns. They have noticed a decrease in self-esteem and have difficulty forming meaningful relationships. The patient states that these feelings have been present for the past two years but have become increasingly distressing over the past six months.
Review of Systems
The patient is negative for fevers, chills, sore throat, and body aches. He reports fatigue and headache. The ROS is negative for constipation, vomiting, rash, runny nose, cough, urinary urgency, dysuria, back pain, abdominal pain, penile discharge, night sweat,
Pt states some diarrhea, diaphoresis, loss of appetite, SOB, and chest pain.
Psychological/Emotional:
Anxiety: The patient reports experiencing persistent anxiety related to their sexual orientation and gender identity.
Depression: The patient describes feelings of sadness, hopelessness, and low mood.
Social Isolation: The patient reports a lack of social support due to difficulties in disclosing their concerns to family and friends.
Self-esteem: The patient expresses a decrease in self-esteem and a negative body image.
Past Medical History:
The patient has no significant past medical history or chronic medical conditions. They have never been hospitalized and have not undergone any surgeries. The patient reports no known allergies to medications or environmental factors.
Physical Exam Findings:
General Appearance:
The patient appears anxious and exhibits signs of distress, including fidgeting and avoiding eye contact. There are no obvious signs of acute distress or distress-related behavior.
Vital Signs:
Blood Pressure: 120/80 mmHg
Heart Rate: 80 beats per minute
Respiratory Rate: 16 breaths per minute
Temperature: 98.6°F (37°C)
Oxygen Saturation: 99% on room air
Skin:
The patient’s skin is intact without any notable lesions, rashes, or discoloration.
HEENT:
Head: Normocephalic, atraumatic
Eyes: Pupils equal, round, and reactive to light. No conjunctival injection.
Ears: No obvious abnormalities or discharge.
Nose: No nasal congestion or discharge.
Throat: Oropharynx is clear, and the tonsils are non-enlarged.
Chest/Lungs:
Clear breath sounds bilaterally, with no adventitious sounds.
Cardiovascular:
Regular rate and rhythm, with no murmurs, rubs, or gallops detected.
Abdomen:
Soft and non-tender to palpation. No masses or organomegaly detected.
Extremities:
No edema, cyanosis, or clubbing. Normal range of motion and intact sensation in all extremities.
Neurological:
Cranial nerves are intact. Strength and sensation are within normal limits. No tremors or abnormal movements observed.
Psychosocial
Noted bouts of crying in the exam room.
PHQ-9 score: 23
GAD 7 score : 19