**Diagnosis: Major Depressive Disorder (MDD)**

Patient presents with symptoms consistent with a diagnosis of Major Depressive Disorder (MDD), single episode, moderate severity.  The patient reports depressed mood, anhedonia, significant weight loss unintentional, insomnia, fatigue, feelings of worthlessness, and diminished concentration for the past six weeks.  These symptoms are present nearly every day and represent a significant change from the patient's baseline. The patient denies suicidal ideation or intent but reports difficulty functioning at work and in social settings.  Clinical findings are consistent with DSM-5 criteria for Major Depressive Disorder.  Differential diagnoses considered include adjustment disorder with depressed mood, bereavement, and medical conditions such as hypothyroidism.  Lab tests including a complete blood count (CBC), comprehensive metabolic panel (CMP), and thyroid stimulating hormone (TSH) were ordered to rule out underlying medical conditions.  The patient's PHQ-9 score is 17, indicating moderate depression.  Treatment plan includes initiation of psychotherapy, specifically Cognitive Behavioral Therapy (CBT), and pharmacotherapy with a selective serotonin reuptake inhibitor (SSRI).  Patient education regarding the course of MDD, medication management, and lifestyle modifications was provided.  Follow-up appointment scheduled in two weeks to assess treatment response and adjust treatment plan as needed.  ICD-10 code: F32.1.  CPT codes for initial evaluation and management visit and psychotherapy session will be applied based on time spent and complexity of medical decision making.

**Diagnosis: Generalized Anxiety Disorder (GAD)**

Patient presents with excessive anxiety and worry occurring more days than not for the past eight months, focusing on work performance, financial stability, and family health.  The patient reports difficulty controlling the worry,  accompanied by symptoms of restlessness, muscle tension, irritability, difficulty sleeping, and fatigue.  These symptoms cause clinically significant distress and impairment in social and occupational functioning.  The patient denies panic attacks or specific phobias.  Symptoms meet DSM-5 criteria for Generalized Anxiety Disorder (GAD).  Differential diagnoses include panic disorder, social anxiety disorder, and medical conditions such as hyperthyroidism.  Physical examination and laboratory tests, including a thyroid panel, were performed to rule out organic causes.  The patient's GAD-7 score is 15, indicating moderate anxiety.  Treatment plan includes initiation of psychotherapy, specifically Cognitive Behavioral Therapy (CBT), and consideration of pharmacotherapy with a selective serotonin reuptake inhibitor (SSRI) or serotonin-norepinephrine reuptake inhibitor (SNRI).  Patient education on stress management techniques, relaxation exercises, and medication management was provided.  Follow-up appointment scheduled in four weeks to monitor symptom improvement and adjust treatment as necessary.  ICD-10 code: F41.1.  CPT codes for evaluation and management and psychotherapy will be determined based on time and complexity of medical decision making.