Depression
Age: years old
Gender:
HISTORY:
Presents with a - history of depressive mood
Symptoms described as
Severity is , significant distress
Negative impact on
Depressive mood is
Recent source of stress: , , ,
Alleviating factors: ,
Associated symptoms: *Try using right-click for negatives*
, , a plan, intent to act
Contributing factors:
no history of: , , ,
no use of:
no family history ,
Smoking: , pack-years
Alcohol: , drinks per
Recreational drugs: ,
EXAM:
Mental Status:
Appearance: , , eye contact, appears
Behavior:
Psychomotor activity:
Speech: , ,
Mood: , ,
Affect: , , , to situation, with mood
Thought process: , , ,
Thought content: , , ,
Perception: , ,
Cognition: , oriented to , disoriented to , attention , memory
Judgment:
Insight: into condition
Reliability:
ASSESSMENT:
DDx: adjustment disorder with depressed mood, major depressive disorder, dysthymia, bipolar disorder, mood disorder due to medical condition, substance-induced depressive disorder, anxiety disorders, personality disorders, psychotic disorders, thyroid disease, anemia, chronic illness, chronic pain syndrome, fibromyalgia, sleep disorder, nutritional deficiencies, neurocognitive disorders, post-traumatic stress disorder, grief reaction, seasonal affective disorder, premenstrual dysphoric disorder
PLAN:
Investigations:
- PHQ-9 questionnaire
- Blood work: ,
- Urine toxicology screen
Treatments:
- Psychoeducation about depression (e.g. causes, prognosis, treatment options)
- Stress management techniques
- Regular exercise
- Healthy diet
- Sleep hygiene
- Avoidance of alcohol and drugs
-
- Cognitive behavioral therapy
Further care:
- Referral to psychologist
- Referral to social worker
- Referral to psychiatrist
- Follow-up in
- Return if condition worsen or if new symptoms develop such as suicidal thoughts
HISTORY: Associated symptoms: EXAM: Mental Status: ASSESSMENT: PLAN: