Depression

HISTORY:

Depressive mood for ‍ ‍hoursdays

Described as: ‍sadnesshopelessnessloss of interest or pleasurefeeling of worthlessness

Severity: ‍mildmoderateseveredebilitating, ‍causingwithout causing significant distress

Negative impact on: ‍daily activitiessocial lifeworkfamilypersonal relationships

Pattern: ‍persistentintermittent

Recent stressors: ‍, ‍work-related issues, ‍personal relationship issues, ‍social issues

Treatments tried: ‍none, ‍effectiveineffective

‍feeling sad

‍hopelessness

‍anxiety

‍worry

‍difficulty concentrating

‍feeling overwhelmed

‍withdrawal from social supports

‍insomnia

‍hypersomnia

‍difficulty taking decisions

‍decreased performance at work/school

‍loss of appetite

‍increased appetite

‍impulsive or risky behaviors

‍suicidal thoughts, ‍persistentintermittent, ‍withwithout a plan, ‍withwithout intent to act

‍hallucinations



Social history:

Smoking: ‍neversmokerformer smoker, ‍ pack-years

Alcohol: ‍nonesociallyexcessive, ‍ drinks per ‍dayweek

Recreational drugs: ‍none ‍cannabis, ‍IVDU



EXAM:

Mental Status:

Appearance: ‍well-dressed, ‍well-groomed, ‍goodpoor eye contact, appears ‍age-appropriate

Behavior: ‍cooperativenon-cooperative

Psychomotor activity: ‍normalretardedagitated

Speech: ‍clear, ‍slowrapid, ‍monotonoustalkative

Mood: ‍euthymicdysthymic, ‍anxious, ‍

Affect: ‍euthymic, ‍reactivenon-reactive, ‍full range, ‍appropriate to situation, ‍congruent with mood

Thought process: ‍organizeddisorganized, ‍coherentincoherent, ‍logicalillogical, ‍

Thought content: ‍normalpreoccupationshopelessness, ‍delusions, ‍suicidal ideations, ‍homicidal ideations

Perception: ‍normal, ‍hallucinations, ‍illusions

Cognition: ‍alert, oriented to ‍3 spheres, attention ‍intactdistractible, memory ‍intactimpaired

Judgment: ‍goodmoderatepoor

Insight: ‍goodmoderatepoor into condition

Reliability: ‍goodmoderatepoor



ASSESSMENT:

‍Adjustment disorderDepressive disorder ‍likelysuspectedpossible

DDx: ‍



PLAN:

- PHQ-9 questionnaire

- Blood work: ‍CBC, ‍TSH

- Urine toxicology screen

- Psychoeducation about depression (e.g. causes, prognosis, treatment options)

- Stress management techniques

- Regular exercise

- Healthy diet

- Sleep hygiene

- Avoidance of alcohol and drugs

- ‍Antidepressants

- Cognitive behavioral therapy

- Referral to psychologist

- Referral to social worker

- Referral to psychiatrist

- Follow-up in ‍ ‍weeksmonths

- Return if condition worsen or if new symptoms develop such as suicidal thoughts