Depression follow-up

Age: ‍ years old

Gender: ‍malefemale



HISTORY:

Returns for a ‍depression follow-up

Last visit was ‍ ‍months ago

Progress since last visit: ‍unchangedimproveddeterioratedvariableresolved

Current stressors: ‍ ‍none, ‍changes at work, ‍end of a relationship, ‍health issues, ‍death of a loved one, ‍life transition



Updates on symptoms:

‍feeling sad

‍hopelessness

‍anxiety

‍worry

‍difficulty concentrating

‍feeling overwhelmed

‍withdrawal from social supports

‍insomnia

‍hypersomnia

‍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



Medications:

‍SSRIs, ‍SNRIs, ‍tricyclics, ‍others, ‍atypical antipsychotics, ‍sedatives

Change at last visit: ‍ ‍introducedincreased, ‍effectiveineffective, ‍adverse effects

Use of sedative: ‍neverrarelyoccasionallyfrequentlydaily

Adherence: ‍goodaveragepoor



Psychotherapy: ‍completedongoingabandonednot interested ‍, ‍effectiveineffective,

Other interventions: ‍ ‍none, ‍supportive relationships, ‍coping strategies, ‍cognitive behavioral therapy, ‍mindfulness-based stress reduction, ‍effectiveineffective



Smoking: ‍neversmokerformer smoker, ‍ pack-years

Alcohol: ‍nonesociallyexcessive, ‍ drinks per ‍dayweek

Recreational drugs: ‍none ‍cannabis, ‍IVDU



Labs: TSH: ‍ ‍normal, Hb: ‍ ‍normal





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, disoriented to ‍, attention ‍intactdistractible, memory ‍intactimpaired

Judgment: ‍goodmoderatepoor

Insight: ‍goodmoderatepoor into condition

Reliability: ‍goodmoderatepoor





ASSESSMENT:

‍Depression ‍likelysuspectedpossible, ‍well-managed

DDx: major depressive disorder, dysthymia, adjustment disorder, bipolar disorder, cyclothymic disorder, anxiety disorders, personality disorders, schizophrenia, substance use disorders, substance-induced depressive disorder, depressive disorder due to medical condition, thyroid disorders, anemia, chronic pain syndromes, chronic fatigue syndrome, sleep disorders, nutritional deficiencies





PLAN:

Investigations:

- PHQ-9 questionnaire

- Blood work: ‍CBC, ‍TSH, ‍LFs, ‍vitamin B12, ‍testosterone

- Urine toxicology screen

- Sleep study

Treatments:

- Psychoeducation about depression

- Encourage to actively self-mobilize

- Encourage to participate in social activities

- Stress management techniques

- Regular exercise

- Healthy diet

- Sleep hygiene

- Avoidance of alcohol and drugs

- ‍Antidepressants

- ‍Sedatives

- ‍Antipsychotics

- ‍Stimulants

- Cognitive behavioral therapy

- Occupational therapy

- Light therapy

- Electroconvulsive therapy

Further care:

- 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