### Demographic Data
– **Patient’s Age and Gender Identity:**
– Age: 45
– Gender Identity: Female
### Subjective
– **Chief Complaint (CC):**
– “I’ve been feeling extremely sad and hopeless for the past few weeks, and I can’t seem to shake it off.”
– **History of Present Illness (HPI):**
– **Reason for Appointment Today:** The patient reports a persistent low mood, lack of interest in daily activities, and feelings of hopelessness and worthlessness. She has been experiencing these symptoms for the past six weeks, which have progressively worsened.
– **Events Leading to Hospitalization/Clinic Visit:** The patient states that her depressive symptoms have severely impacted her ability to function at work and home. She has also noticed a significant decrease in her energy levels and concentration.
– **Symptoms:** Depressed mood, anhedonia, fatigue, insomnia, difficulty concentrating, and significant weight loss without trying.
– **Relieving Factors:** Temporary relief from symptoms when engaging in hobbies, but these moments are fleeting.
– **Past Compliance/Non-Compliance with Medications:** The patient reports adherence to her previous antidepressant regimen but discontinued the medication six months ago due to perceived ineffectiveness.
– **Adverse Effects from Past Medication Use:** The patient experienced mild nausea and headaches when she was on the medication.
– **Sleep Patterns:** The patient reports sleeping 3-4 hours per night, with early morning awakenings and difficulty falling back asleep.
– **Suicide or Homicide Thoughts Present:** The patient denies any current suicidal or homicidal ideation but admits to having fleeting thoughts of self-harm.
– **Self-Care or ADL Issues:** The patient reports neglecting personal hygiene and having difficulty preparing meals.
– **Psychosis:** No presence of psychosis.
– **Past Psychiatric History (PSH):**
– **Past Psychiatric Diagnoses:** Major Depressive Disorder (MDD)
– **Past Hospitalizations:** None
– **Past Psychiatric Medications:** Sertraline 50 mg daily, discontinued six months ago.
– **Non-Compliance Issues:** None reported.
– **Medications That Didn’t Work:** Sertraline was perceived as ineffective.
– **Family History of Psychiatric Conditions or Diagnoses:**
– **Mother:** Diagnosed with depression.
– **Father:** No known psychiatric conditions.
– **Siblings:** One brother with anxiety disorder.
– **Grandparents:** Paternal grandmother had bipolar disorder.
– **Social History:**
– **Nutrition:** Poor appetite, unintentional weight loss of 10 pounds in the past month.
– **Exercise:** None regularly.
– **Substance Use:** Occasional alcohol use, no illicit drug use.
– **Sexual History/Preference:** Heterosexual, married, reports no current sexual activity due to lack of interest.
– **Occupation:** Office manager
– **Highest School Achievement:** Bachelor’s degree in business administration.
– **Financial Problems:** None reported.
– **Legal Issues:** None reported.
– **Children:** Two children, ages 10 and 15.
– **History of Personal Abuse:** Denies any history of sexual, emotional, or physical abuse.
– **Allergies:**
– No known drug allergies (NKDA).
– **Review of Systems (ROS):**
– **Physical Complaints:** Reports occasional tension headaches, no respiratory or cardiac complaints, no renal issues.
### Objective
– **Mental Status Exam:**
– **Appearance:** Disheveled, poor grooming.
– **Behavior:** Appears fatigued and slowed movements.
– **Mood:** Depressed
– **Affect:** Blunted
– **Speech:** Slow, monotonous
– **Thought Process:** Logical, but slow
– **Thought Content:** No delusions or hallucinations
– **Cognition:** Alert and oriented to person, place, and time; difficulty with concentration.
– **Insight and Judgment:** Fair
### Assessment (Diagnosis)
– **Differential Diagnoses:**
1. **Generalized Anxiety Disorder (GAD) – ICD-10 F41.1**
– **Rationale:** Symptoms of difficulty concentrating, fatigue, and sleep disturbances are common in GAD but the predominant features of persistent low mood and anhedonia suggest otherwise.
2. **Persistent Depressive Disorder (Dysthymia) – ICD-10 F34.1**
– **Rationale:** Chronic depression lasting for more than two years is a key feature, whereas the patient’s symptoms have been present for a shorter duration and are more severe.
– **Working Diagnosis:**
– **Major Depressive Disorder, Recurrent Episode, Moderate – ICD-10 F33.1**
– **Rationale:** The patient meets DSM-5 criteria for MDD with a history of depressive episodes, current symptoms of depressed mood, anhedonia, significant weight loss, insomnia, fatigue, and difficulty concentrating for the past six weeks.
### Plan
– **Treatment Plan (Tx Plan):**
– **Pharmacologic:**
– **Medication:** Escitalopram 10 mg daily.
– **Rationale:** Selected due to the patient’s previous experience with SSRIs and mild side effects.
– **Refill Provided:** N/A as this is a new prescription.
– **Patient Education:**
– **Medication Teaching Points:** Importance of adherence, potential side effects, and the need for regular follow-up.
– **Risk vs. Benefit:** Discussed the benefits of reducing depressive symptoms against potential side effects.
– **Prognosis:**
– **Decision:** Fair
– **Rationale:** The patient’s willingness to adhere to treatment and absence of severe comorbidities support a fair prognosis.
– **Therapy Recommendations:**
– **Type:** Cognitive Behavioral Therapy (CBT)
– **Rationale:** Effective for depression and anxiety, helping to change negative thought patterns.
– **Referral/Follow-up:**
– **Follow-up with Psychiatrist:** In four weeks to monitor medication effectiveness and adjust dosage if necessary.
– **Rationale:** To ensure close monitoring and support during the initial treatment phase.
### References
– American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
– Smith, R. A., et al. (2020). Cancer screening in the United States, 2020: A review of current American Cancer Society guidelines and current issues in cancer screening. *CA: A Cancer Journal for Clinicians, 70*(1), 17-35.
– Still, C. H., & Wright, J. T. (2022). Intersections Among Sociocultural and Environmental Issues in Adulthood and Childhood Cardiovascular Health and Hypertension. *A Population Health Approach to Health Disparities for Nurses: Care of Vulnerable Populations*.
Demographic Data
· Patient’s age and patient’s gender identity
· IT MUST BE HIPAA compliant.
Subjective
· Chief Complaint (CC):
· Place the patient’s CC complaint in Quotes
· History of Present Illness (HPI):
· Reason for an appointment today.
· The events that led to hospitalization or clinic visits today.
· Include symptoms, relieving factors, and past compliance or non-compliance with medications
· Any adverse effects from past medication use
· Sleep patterns – number of hours of sleep per day, early wakefulness, inability to initiate sleep, inability to stay asleep, etc.
· Suicide or homicide thoughts present
· Any self-care or Activity of Daily Living (ADL) such as eating, drinking liquids, self-care deficits, or issues noted?
· Presence/description of psychosis (if psychosis, command or non-command)
· Past Psychiatric History (PSH):
· Past psychiatric diagnoses
· Past hospitalizations
· Past psychiatric medications use
· Any non-compliance issues in the past?
· Any meds that didn’t work for this patient?
· Family History of Psychiatric Conditions or Diagnoses:
· Mother/father, siblings, grandparents, or direct relatives
· Social History:
· Include nutrition, exercise, substance use (details of use), sexual history/preference, occupation (type), highest school achievement, financial problems, legal issues, children, and history of personal abuse (including sexual, emotional, or physical).
· Allergies:
· To medications, foods, chemicals, and others.
· Review of Systems (ROS) (Physical Complaints):
· Any physical complaints by the body system? (Respiratory, Cardiac, Renal, etc.)
Objective
· Mental Status Exam:
· This is not a physical exam.
· Mental Status Exam (MSE)
Assessment (Diagnosis)
· Differentials
· Two (2) differential diagnoses with ICD-10 codes.
· Must include rationale using DSM-5 Criteria (Required)
· Why didn’t you pick these as a major diagnosis?
· Working Diagnosis
· Final or working diagnosis (1), with ICD-10 code.
· Must include rationale using DSM-5 criteria required – Which symptoms/signs in the DSM-5 the patient matches mostly)
Plan
· Treatment Plan (Tx Plan):
· Pharmacologic: Include complete information for each medication(s) prescribed
· Refill Provided: Include complete information for each medication(s) refilled
· Patient Education:
· Including specific medication teaching points
· Was the risk versus benefit of the current treatment plan addressed for meds or treatment
· Risk versus benefit of non-FDA approved for working diagnosis – Off-label use of medication education to patient addressed?
· Prognosis:
· Make Decision for prognosis: Good, Fair, Poor
· Provide brief statement lending support for or against the decided prognosis.
· Therapy Recommendations:
· Type(s) of therapy recommended.
· Referral/Follow-up:
· Did you recommend follow-up with a Psychiatrist, PCP, or other specialist or healthcare professionals?
· When is the subsequent follow-up?
· Include the rationale for the F/U recommendation or referral.
Reference(s):
· Include American Psychological Association (APA) formatted references.
· Include a reference from the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Health Disorders (DSM-5) or the accompanying Desk Reference of Diagnostic Criteria from DSM-5.
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