History of Presenting Complaints:
- The patient, [insert age] year old male, presents today with complaints of persistent low mood, anhedonia, and difficulty concentrating, which started approximately 6 months ago. He reports feeling sad most days, with a loss of interest in activities he previously enjoyed, such as playing video games and socialising with friends. He also reports significant fatigue and changes in appetite, with associated weight loss. He denies any suicidal ideation or attempts at this time.
- The patient reports experiencing anxiety symptoms, including racing thoughts and difficulty sleeping. He also reports feeling overwhelmed by work-related stress.
- The patient reports a family history of depression, with his mother having been diagnosed with the condition. He has been experiencing these symptoms for the last 6 months.
Past Medical & Psychiatric History:
- The patient has no prior psychiatric diagnoses or hospitalizations. He has been diagnosed with depression and anxiety.
- The patient has no chronic medical conditions.
Medications:
- The patient is currently taking Sertraline 50mg daily for depression and anxiety.
Family History:
- The patient's mother has a history of depression, treated with medication and therapy.
Social History:
- The patient is employed as a software engineer and has a bachelor's degree.
- The patient denies smoking, alcohol, or recreational drug use.
- The patient reports having a supportive network of friends and family.
Childhood history:
- The patient reports a normal birth and developmental history. He had a happy childhood.
- The patient reports a good relationship with his parents and siblings.
- The patient reports being bullied in school.
Menstrual history:
- N/A
Psychosexual history:
- The patient identifies as heterosexual and reports no adverse sexual experiences.
Mental Status Examination:
- Appearance: The patient is well-groomed and dressed appropriately for the weather.
- Behaviour: The patient appears slightly restless, fidgeting in his chair. He makes good eye contact.
- Speech: The patient's speech is normal in rate and volume, with no notable abnormalities.
- Mood: The patient reports feeling "sad" and "anxious."
- Affect: The patient's affect is congruent with his stated mood, appearing sad and somewhat restricted.
- Thoughts: The patient reports experiencing negative thoughts about himself and his future. He denies any suicidal ideation or homicidal ideation. He reports anxious rumination about work.
- Perceptions: The patient denies any hallucinations or perceptual disturbances.
- Cognition: The patient is alert and oriented to person, place, and time. His memory appears intact.
- Insight: The patient acknowledges that he is experiencing symptoms of depression and anxiety and understands that these symptoms are causing him distress.
- Judgment: The patient demonstrates good judgment and decision-making abilities.
Risk Assessment:
- The patient denies suicidal or homicidal ideation. He denies any plans or intent to harm himself or others.
Diagnosis:
- Major Depressive Disorder, Recurrent, Moderate (F33.1) and Generalised Anxiety Disorder (F41.1) based on DSM-5 criteria.
Formulation:
- The patient is a [insert age] year old male presenting with symptoms of low mood, anhedonia, and anxiety. He reports a family history of depression and has been experiencing these symptoms for the last 6 months. He is seeking help to address his symptoms and improve his overall well-being.
- Several factors may be contributing to the patient's current presentation, including genetic predisposition, work-related stress, and a history of bullying. The patient's premorbid personality appears to be introverted and conscientious. He has a supportive social network, but his coping mechanisms appear to be limited.
- The patient's current presentation is likely a result of the interplay between his genetic vulnerability, environmental stressors, and limited coping mechanisms. The diagnosis of Major Depressive Disorder, Recurrent, Moderate, and Generalised Anxiety Disorder is supported by the patient's symptoms and history. The prognosis is good with appropriate treatment.
Treatment Plan:
- Planned investigations: None.
- Medication plans including changes, continuing medicatins, prescriptions, medications ceased or any other medication related plans: Continue Sertraline 50mg daily. Consider increasing the dose to 100mg daily in 4 weeks if symptoms do not improve. Discuss the potential benefits and risks of medication with the patient.
- Psychotherapy plans and strategies: Recommend Cognitive Behavioral Therapy (CBT) to address negative thought patterns and develop coping skills. Refer the patient to a therapist specializing in CBT.
- Planned family meetings & collateral information, psychosocial interventions: Encourage the patient to engage in social activities and maintain a healthy lifestyle. Consider involving the patient's family in therapy if appropriate.
- Follow-up appointments and referrals: Schedule a follow-up appointment in 4 weeks to assess the patient's response to treatment. Refer the patient to a therapist for CBT.
Safety Plan:
- The patient has been educated on the signs and symptoms of worsening depression and anxiety. He has been provided with a list of crisis resources and instructed to contact them if needed. He has been encouraged to reach out to his support network if he feels overwhelmed.
History of Presenting Complaints:
- [Describe current issues with all available details, reasons for visit, and complete history of presenting complaints.] (Only include if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- [Describe any other associated symptoms with details.] (Only include if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- [Describe any relevant history obtained for any of the diagnosis and ruled out in the transcript.] (Only include if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
Past Medical & Psychiatric History:
- [Describe past psychiatric diagnoses, treatments, hospitalizations.] (Only include if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- [List chronic medical conditions.] (Only include if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
Medications:
- [List current medications.] (Only include if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
Family History:
- [Note any psychiatric illnesses within the family, specifying the relationship to the patient and the nature of the illnesses.] (Only include if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
Social History:
- [Occupation, level of education.] (Only include if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- [Substance use such as smoking, alcohol, recreational drugs.] (Only include if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- [Social support.] (Only include if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
Childhood history:
- [Include relevant information related to birth, developmental and childhood history.] (Only include if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- [Provide information on the relationship with significant carers, siblings and other family members.] (Only include if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- [Provide information on school including any bullying, adverse experiences and academic performance.] (Only include if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
Menstrual history:
- [Provide details of menstrual cycles, regularity, flow and any gynaecological issues mentioned in the transcript.] (Only include if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
Psychosexual history:
- [Describe sexual orientation, gender identity and any adverse sexual experiences described in the transcript.] (Only include if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
Mental Status Examination:
- Appearance: [Describe the patient's clothing, hygiene, and any notable physical characteristics.] (Only include appearance details if they have been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- Behaviour: [Observe the patient's activity level, interaction with their surroundings, and any unique or notable behaviors.] (Only include behaviour details if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- Speech: [Note the rate, volume, clarity, and coherence of the patient's speech.] (Only include speech characteristics if they have been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- Mood: [Record the patient's self-described emotional state, using their own words if possible.] (Only include self-described emotional state if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- Affect: [Describe the range and appropriateness of the patient's emotional response during the examination, noting any discrepancies with the stated mood.] (Only include if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- Thoughts: [Assess the patient's thought process and thought content, noting any distortions, delusions, or preoccupations.] [Extract relevant details from the transcript which reflect the patient's thoughts such as any depressive cognition, anxious rumination, obsessive-compulsive thoughts, excessive preoccupation with eating or body image, preoccupation with any stressors, self-harm and suicidal thoughts.] (Only include if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- Perceptions: [Note any reported hallucinations or sensory misinterpretations, specifying type and impact on the patient.] (Only include perception details if they have been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- Cognition: [Describe the patient's memory, orientation to time/place/person, concentration, and comprehension.] (Only include cognitive observations if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- Insight: [Describe the patient's understanding of their own condition and symptoms, noting any lack of awareness or denial.] (Only include insight observations if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- Judgment: [Describe the patient's decision-making ability and understanding of the consequences of their actions.] (Only include judgement observations if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
Risk Assessment:
- [Assessment of suicidality, homicidality, and other risks.] (Only include [Assessment of suicidality, homicidality, other risks] if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
Diagnosis:
- [Insert the diagnosis, relevant DSM-5 criteria, psychological scales/questionnaires.] (Only include diagnosis details if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
Formulation:
- [Provide three paragraphs as formulation.]
- [First paragraph to focus on the source of referral, presenting complaints and relevant past psychiatric and medical history.] (Only include if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- [Second paragraph to focus on relevant factors from different parts of the history such as genetic predisposition, birth and developmental history, trauma history, premorbid personality, significant interpersonal relationships, substance use history, current stressors, coping mechanisms, role of current medications and current psychosocial supports.] (Only include if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- [Third paragraph to focus on linkages between different factors resulting in patient's current presentation and providing diagnostic and prognostic elements.] (Only include if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
Treatment Plan:
- [Planned investigations.] (Only include [investigations] if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- [Medication plans including changes, continuing medicatins, prescriptions, medications ceased or any other medication related plans.] (Only include medication plans if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- [Psychotherapy plans and strategies.] (Only include psychotherapy plans if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- [Planned family meetings & collateral information, psychosocial interventions.] (Only include family meetings and psychosocial interventions if they have been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- [Follow-up appointments and referrals.] (Only include follow-up plans and referrals if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
Safety Plan:
- [Detail safety plan including steps to take in crisis.] (Only include safety plan details if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
(Never come up with your own patient details, assessment, plan, interventions, evaluation, or 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 that the information has not been explicitly mentioned in your output—just leave the relevant placeholder or omit it completely. Use as many lines, paragraphs, or bullet points as needed to capture all the relevant information from the transcript.)
