Medical Report

I. Patient Information

Name: [Patient's Name]
Date of Birth: [Patient's Birthdate]
Gender: Male
Address: [Patient's Address]
Phone Number: [Patient's Contact Number]
Email: [Patient's Email]

II. Chief Complaint

The patient presents with persistent feelings of sadness, hopelessness, and loss of interest in activities that were previously enjoyed. Reports difficulty sleeping and concentrating.

III. History of Present Illness (HPI)

[Patient's Name] reports experiencing depressive symptoms for the past 6 months, which have gradually worsened. The symptoms include pervasive sadness, anhedonia, insomnia, and feelings of worthlessness. There is no history of manic or hypomanic episodes.

IV. Past/Family Psychiatric History

There is no previous psychiatric history reported by the patient. He denies any prior episodes of depression or other mood disorders. The patient reports a family history of depression on his mother's side, with his aunt diagnosed with depressive disorder.

V. Medical History

Hypertension managed with Lisinopril
No history of diabetes or other chronic illnesses

VI. Medications

Currently not taking any prescribed medications. He reports occasional use of over-the-counter medications for sleep aids.

VII. Allergies

No known allergies to medications or environmental substances.

VIII. Mental Status Examination

The patient appears appropriately groomed and cooperative. Speech is fluent and coherent. His affect is congruent with the reported mood of depression. Cognition is intact with no deficits noted in orientation, memory, or concentration.

IX. Diagnostic Assessment

Based on clinical evaluation and DSM-5 criteria, [Patient's Name] meets criteria for Major Depressive Disorder, single episode, moderate severity.

X. Treatment Plan

Initiate pharmacotherapy with Sertraline starting at 50 mg daily.
Referral to psychiatric counseling for cognitive-behavioral therapy (CBT) to address negative thought patterns and behavior activation.
Psychoeducation regarding depression, emphasizing the importance of adherence to treatment and follow-up appointments.
Follow-up appointment scheduled in 4 weeks to assess treatment response and adjust medication as needed.

XI. Prognosis

The prognosis for Major Depressive Disorder is generally favorable with appropriate treatment. With medication adherence and active participation in therapy, [Patient's Name] is expected to experience improvement in mood and overall functioning.

XII. Follow-Up Instructions

Please ensure [Patient's Name] attends scheduled follow-up appointments with our clinic. Contact 222 555 7777 for any urgent concerns or significant changes in his condition.

This report is based on the information obtained during the initial assessment. Any additional findings or updates should be documented in subsequent progress notes.