Depressive Mood

Age: ‍ years old

Gender: ‍malefemale



HISTORY:

Presents with a ‍-‍day history of depressive mood

Symptoms described as ‍sadnessloss of interest or pleasurefeeling of worthlessness

Severity is ‍mildmoderateseveredebilitating, ‍causingwithout causing significant distress

Negative impact on ‍daily activitiessocial lifeworkfamilypersonal relationships

Depressive mood is ‍persistentintermittent

Recent source of stress: ‍, ‍work-related issues, ‍personal relationship issues, ‍social issues

Alleviating factors: ‍none, ‍effectiveineffective



Associated symptoms: *Try using right-click for negatives*

‍loss of interest or pleasure in activities

‍significant weight loss or gain

‍insomnia or hypersomnia

‍psychomotor agitation or retardation

‍fatigue or loss of energy

‍feelings of worthlessness or excessive guilt

‍diminished ability to think or concentrate

‍decreased libido

‍feelings of hopelessness or helplessness

‍difficulty making decisions

‍persistent sadness or emptiness

‍irritability or restlessness

‍social withdrawal or isolation

‍changes in appetite or eating habits

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

‍hallucinations



Contributing factors:

‍substance abuse

no history of: ‍major depression, ‍bipolar disorder, ‍anxiety disorders, ‍substance use disorders

no use of: ‍new medication

no family history ‍depressive disorders, ‍bipolar disorder



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, disoriented to ‍, attention ‍intactdistractible, memory ‍intactimpaired

Judgment: ‍goodmoderatepoor

Insight: ‍goodmoderatepoor into condition

Reliability: ‍goodmoderatepoor





ASSESSMENT:

‍Adjustment disorderDepressive disorder ‍likelysuspectedpossible

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: ‍CBC, ‍TSH

- 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

- ‍Antidepressants

- Cognitive behavioral 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