Major Depressive Episode follow-up
Age: years old
Gender:
HISTORY:
Returns for a follow-up
Last visit was ago
Progress since last visit:
Current stressors: , , , , ,
Updates on symptoms:
, , a plan, intent to act
Medications:
, , , , ,
Change at last visit: , ,
Use of sedative:
Adherence:
Psychotherapy: , ,
Other interventions: , , , , ,
Smoking: , pack-years
Alcohol: , drinks per
Recreational drugs: ,
Labs: TSH: , Hb:
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: 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: , , , ,
- 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
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- Cognitive behavioral therapy
- Occupational therapy
- Light therapy
- Electroconvulsive 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: EXAM: Mental Status: ASSESSMENT: PLAN: