**Initial Psychiatric Assessment**
**Background:**
Mr. John Smith, a 35-year-old male, identifies as heterosexual. He is married with two children and works as a software engineer.
**Reason for Assessment / Referral:**
Mr. Smith was referred for a psychiatric assessment by his GP due to increasing symptoms of low mood, anxiety, and difficulty sleeping. The purpose of the assessment is to evaluate his symptoms and determine an appropriate course of treatment.
**History of Presenting Illness:**
Mr. Smith reports that his symptoms began approximately six months ago, gradually worsening over time. He initially experienced mild feelings of sadness and worry, which have escalated to the point where they significantly impact his daily functioning. He reports that the symptoms are worse in the mornings and improve slightly in the evenings. He has not sought any treatment for these symptoms previously.
Current Symptoms: Low mood, anhedonia, anxiety, insomnia, fatigue, poor concentration.
Impact on Functioning: Difficulty at work, withdrawal from social activities, strained relationship with his wife, neglecting self-care.
Coping and Insight: Mr. Smith reports that he has tried to cope by increasing his exercise, but this has not been effective. He acknowledges that his symptoms are impacting his life and is seeking help.
**Past Psychiatric History:**
Mr. Smith denies any previous psychiatric diagnoses, hospitalisations, or psychological therapies.
History of Self-harm or Suicidal Thoughts: Denies any history of self-harm or suicidal ideation.
**Family Psychiatric History:**
His mother has a history of depression, and his maternal grandmother died by suicide.
**Family Dynamics:**
Mr. Smith describes his childhood as generally positive, although he reports feeling pressure to succeed from his parents.
**Drug and Alcohol History:**
Mr. Smith reports drinking alcohol socially, approximately once or twice a week. He denies any recreational drug use. He is a non-smoker.
**Forensic History:**
Denies any history of legal trouble.
**Medical History:**
Mr. Smith has no significant medical history.
**Meds/Allergies:**
* None
**Developmental, Personal & Social History:**
Mr. Smith reports a normal developmental history. He had a happy childhood and did well in school. He has always been a high achiever. He reports being bullied at school.
Adolescence: Mr. Smith reports that he struggled with low mood and anxiety during adolescence, but these symptoms resolved without intervention.
Trauma History: Denies any history of trauma.
Social Circumstances and Support Network: Mr. Smith is married and lives with his wife and two children. He has a supportive network of friends and family.
**Mental State Examination:**
Mr. Smith is a well-groomed, cooperative male who makes good eye contact. His speech is normal in rate and rhythm. His mood is low, and his affect is constricted. His thought process is linear and goal-directed. He denies any hallucinations or delusions. His cognition is intact. He demonstrates good insight and judgment.
**Risk Assessment:**
Mr. Smith denies any current risk to self or others. He has protective factors including a supportive family and a strong desire to get better.
**Formulation**
Predisposing
* Family history of depression.
* Personality traits of perfectionism and high achievement.
Precipitating
* Work-related stress.
* Relationship difficulties.
Perpetuating
* Negative thought patterns.
* Social isolation.
Protective
* Strong social support.
* Good insight.
* Motivation to seek treatment.
**Impression / Summary:**
Mr. Smith presents with symptoms consistent with a major depressive episode. He is experiencing significant distress and impairment in multiple areas of his life. He is motivated to engage in treatment.
**Diagnosis / Provisional Diagnosis:**
Major Depressive Disorder, single episode (F32.9)
**Plan and Recommendations:**
* Initiate antidepressant medication (e.g., sertraline).
* Recommend cognitive behavioural therapy (CBT).
* Schedule follow-up appointment in four weeks.
* Provide psychoeducation about depression and treatment options.
**Initial Psychiatric Assessment**
**Background:**
[describe the patient's age, gender, race, whether they are married and if they have any children, their occupation] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write this section in a narrative format in third person using the patient's name and appropriate pronouns. Ensure each sentence begins with the patient's name or the appropriate pronoun.)
**Reason for Assessment / Referral:**
[briefly outline the referral source, purpose of the assessment, and key presenting concerns] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in a narrative format in third person using the patient's name and appropriate pronouns. Ensure each sentence begins with the patient's name or the appropriate pronoun.)
**History of Presenting Illness:**
[document the history of the presenting illness, including onset, duration, and progression of symptoms] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in a narrative format in third person using the patient's name and appropriate pronouns. Ensure each sentence begins with the patient's name or the appropriate pronoun.)
Current Symptoms: [describe current symptoms including mood, sleep, energy, anxiety, irritability, attention, motivation, etc.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in shorthand style.)
Impact on Functioning: [document impact on work, relationships, parenting, self-care, and social life] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in shorthand style.)
Coping and Insight: [describe how the person understands their difficulties; any self-help or coping strategies] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in shorthand style.)
**Past Psychiatric History:**
[detail any past psychiatric history, including previous diagnoses, psychological therapies, treatments, and hospitalisations] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in paragraph format.)
History of Self-harm or Suicidal Thoughts: [document any past or present self-harm or suicidal ideation, including context and risk if applicable] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in shorthand style.)
**Family Psychiatric History:**
[describe relevant psychiatric conditions in family, including mood disorders, neurodevelopmental conditions, and suicide] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in shorthand style.)
**Family Dynamics:**
[describe parenting style, attachment patterns, family trauma if relevant] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in shorthand style.)
**Drug and Alcohol History:**
[document any past or current substance use, including smoking, alcohol, and recreational drugs; elaborate on features of dependence or withdrawal only if mentioned explicitly] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in shorthand style.)
**Forensic History:**
[document any history of legal trouble, including charges or arrests] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in shorthand style.)
**Medical History:**
[document past and current medical history, including chronic conditions, surgeries, and hospitalisations] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in paragraph format.)
**Meds/Allergies:**
[list current medications with dosages, and any known allergies] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in list format.)
**Developmental, Personal & Social History:**
[describe the patient's developmental history, childhood experiences, schooling and peer relationships, including any bullying at school] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in full sentences and paragraph format.)
Adolescence: [describe mood, identity development, and relationships during adolescence] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in paragraph format.)
Trauma History: [describe any history of emotional, physical or sexual abuse, or neglect] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in paragraph format.)
Social Circumstances and Support Network: [document current living situation, education, employment, social support, and relationship status] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in full sentences and paragraph format.)
**Mental State Examination:**
[document findings from the mental state examination including appearance, behaviour, speech, mood, thought content, thought process, perception, cognition, and insight] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in flowing sentences and paragraph format.)
**Risk Assessment:**
[document any current risk factors including risk to self, others, or from others; include protective factors] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in paragraph format.)
**Formulation**
Predisposing
[family history, early life experiences, or personality factors contributing to current difficulties] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in bullet point format.)
Precipitating
[recent stressors or triggers such as losses or transitions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in bullet point format.)
Perpetuating
[ongoing factors that maintain symptoms such as relationships, environment, or cognitive habits] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in bullet point format.)
Protective
[insight, motivation, strengths, or supports] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in bullet point format.)
**Impression / Summary:**
[provide a summary of the clinical presentation, assessment findings, and likely diagnosis] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in a narrative format in third person using the patient's name and appropriate pronouns. Ensure each sentence begins with the patient's name or the appropriate pronoun.)
**Diagnosis / Provisional Diagnosis:**
[document working or confirmed diagnosis using ICD-11 or DSM-5 format; if no diagnosis is reached, explain why] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
**Plan and Recommendations:**
[document proposed investigations, medication recommendations, psychological therapies, signposting, follow-up plans or referrals] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in bullet point format.)
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely. Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)
