Reason for Visit:
- Patient presents with worsening depressive symptoms and anxiety over the past three months.
History of Present Illness:
- The patient reports a gradual onset of depressive symptoms, including persistent sadness, lack of energy, and difficulty concentrating. Anxiety symptoms include restlessness and excessive worry.
Past Psychiatric History:
- The patient has a history of major depressive disorder, previously hospitalized for suicidal ideation two years ago. Past treatments include cognitive behavioral therapy and sertraline, which was discontinued due to side effects.
Past Medical History:
- The patient has a history of hypothyroidism, managed with levothyroxine.
Medications:
- Currently taking fluoxetine 20 mg daily for depression.
Allergies:
- No known drug allergies.
Medication Trials:
- Previous trials of sertraline and escitalopram, both discontinued due to gastrointestinal side effects.
Access to Weapons:
- No access to firearms or other weapons.
Social History:
- Lives alone in an apartment, has a supportive network of friends.
Education:
- Completed a bachelor's degree in psychology.
Relationships:
- Close relationship with parents and one sibling, no current intimate relationship.
Work:
- Employed as a social worker, reports moderate work-related stress.
Supports:
- Attends weekly support group meetings and has regular therapy sessions.
Protective Factors:
- Strong support system, engaged in therapy, and motivated for treatment.
Negative Factors:
- Occasional alcohol use, reports feeling isolated at times.
Suicide Risk Assessment:
- Denies current suicidal ideation, intent, or plan. Protective factors include strong family support and engagement in therapy.
Forensic History:
- No history of legal issues or arrests.
Family History:
- Family history of depression in mother and substance abuse in father.
Mental Status Exam:
- Appearance: Well-groomed. Behavior: Cooperative. Speech: Normal rate and volume. Mood: Depressed. Affect: Constricted. Thought Process: Linear. Thought Content: No delusions or hallucinations. Cognition: Intact. Insight/Judgment: Good.
Objective Findings:
- No significant findings on recent physical exam.
Diagnosis:
- Major Depressive Disorder, Recurrent, Moderate.
Diagnostic Formulation:
- Biopsychosocial factors include genetic predisposition, work stress, and social isolation contributing to the current depressive episode.
Assessment and Plan:
- Continue fluoxetine 20 mg daily. Increase therapy sessions to twice weekly. Encourage participation in social activities. Follow-up in four weeks to assess progress.
Reason for Visit:
- [describe reason for visit] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
History of Present Illness:
- [describe history of present illness, including onset, duration, and progression of psychiatric symptoms] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Past Psychiatric History:
- [describe past psychiatric history, including hospitalizations, treatments, diagnoses, and outcomes] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Past Medical History:
- [describe past medical history, focusing on any conditions that may impact psychiatric health] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Medications:
- [mention current medications, including psychiatric medications and dosages] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Allergies:
- [mention allergies] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Medication Trials:
- [describe previous psychiatric medication trials, including efficacy and side effects] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Access to Weapons:
- [describe access to weapons or firearms] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Social History:
- [describe social history, including living situation, relationships, and support systems] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Education:
- [describe education history and current educational level] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Relationships:
- [describe interpersonal relationships, including family dynamics and intimate relationships] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Work:
- [describe work history, current employment status, and any work-related stressors] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Supports:
- [describe supports, including social, community, and therapeutic supports] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Protective Factors:
- [describe protective factors, such as coping strategies, support systems, and resilience factors] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Negative Factors:
- [describe negative factors or stressors, such as substance use, lack of support, or ongoing trauma] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Suicide Risk Assessment:
- [describe suicide risk assessment, including ideation, intent, plan, and protective factors] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Forensic History:
- [describe legal history, including arrests, charges, orders of protection, bail, probation or parole] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Family History:
- [describe family psychiatric and medical history, including any history of mental illness or substance abuse] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Mental Status Exam:
- [describe mental status exam findings, including appearance, behavior, speech, mood, affect, thought process, thought content, perceptual disturbances, cognition, and insight/judgment] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Objective Findings:
- [describe objective findings, such as physical exam or lab results] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Diagnosis:
- [mention diagnosis based on DSM-5 criteria] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Diagnostic Formulation:
- [describe diagnostic formulation, including biopsychosocial factors contributing to the diagnosis] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Assessment and Plan:
- [describe assessment and plan, including treatment goals, interventions, medications, and follow-up recommendations] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
(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 section blank.)
(Use as many bullet points as needed to capture all the relevant information from the transcript.)
