Psychiatric Consultation

Patient Identification: - Name: John Doe - Age: 45 - Gender: Male - ID Number: 123456 History of Presenting Illness: John Doe presented with symptoms of severe depression, including persistent sadness, lack of interest in daily activities, and difficulty sleeping, which have been ongoing for the past six months. He reports that these symptoms have significantly impacted his work performance and relationships. He denies any specific triggers but notes that symptoms worsen during stressful periods. Past Psychiatric History: John has a history of major depressive disorder diagnosed five years ago. He was previously treated with cognitive behavioral therapy and sertraline, which he discontinued two years ago after symptom improvement. Past Medical History: John has a history of hypertension, managed with lisinopril. He underwent appendectomy at age 30. Medications: - Lisinopril 10 mg daily for hypertension - Over-the-counter melatonin for sleep Substance Use History: John reports occasional alcohol use, approximately 2-3 drinks per week, and denies any history of tobacco or recreational drug use. Family Psychiatric History: His mother had a history of depression, and his brother was diagnosed with bipolar disorder. Legal History: John has no significant legal history. Mental Status Examination (MSE): - Appearance: Well-groomed, casually dressed - Behavior: Cooperative, maintained good eye contact - Speech: Normal rate and volume - Mood: "I feel down most of the time." - Affect: Blunted - Thought Process: Logical and coherent - Thought Content: No delusions or hallucinations - Cognition: Alert and oriented to person, place, and time - Insight: Good - Judgment: Intact Impression and Recommendations: Impression: Major depressive disorder, recurrent, moderate Recommendations: Restart sertraline 50 mg daily, refer to psychotherapy for cognitive behavioral therapy, and schedule follow-up in four weeks. Educate patient on medication adherence and managing symptoms.