Medical Report

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 a 6-month history of persistent depressive symptoms, including sadness, hopelessness, and loss of interest in activities such as reading and hiking, which he previously enjoyed. He also reports difficulty sleeping, often waking up during the night, and problems concentrating at work, leading to decreased productivity. He has become increasingly irritable and tired and reports low energy throughout the day. There are no reports of suicidal ideation, but he expresses feelings of overwhelm.

III. History of Present Illness (HPI)

[Patient's Name] reports that his symptoms began approximately 6 months ago following the death of a close friend. Initially, he felt mild sadness and tiredness, which worsened over time. He now experiences persistent sadness, insomnia, and anhedonia (inability to find pleasure in activities). He describes feelings of worthlessness and self-doubt that affect his work as a project manager, where he has noticed decreased performance and struggles to complete tasks. There is no history of manic or hypomanic episodes, and he denies any substance abuse.

IV. Past/Family Psychiatric History

  • Personal Psychiatric History: John reports no prior psychiatric treatment. He has never been diagnosed with depression, anxiety, or any other mental health conditions, and has never been hospitalized for mental health reasons.

  • Family Psychiatric History: He mentions that his maternal aunt was diagnosed with Major Depressive Disorder and has been on medication for many years. His mother has also experienced periodic depressive episodes but has not sought formal treatment. There is no known family history of bipolar disorder, schizophrenia, or substance abuse.

V. Medical History

  • Diagnosed with Hypertension 5 years ago, currently managed with Lisinopril 10 mg daily.

  • No history of diabetes, heart disease, or respiratory issues.

  • No previous surgeries or hospitalizations.

  • Immunizations are up to date.

VI. Medications

  • Current Medications: John is not currently taking any prescribed psychiatric medications.

  • He reports the occasional use of over-the-counter sleep aids, such as diphenhydramine (Benadryl), to help with his insomnia, usually 2-3 times a week.

  • He takes Lisinopril 10 mg daily for hypertension.

VII. Allergies

  • No known drug allergies (NKDA).

  • No food or environmental allergies were reported.

VIII. Mental Status Examination

  • Appearance: John appeared well-groomed and appropriately dressed for the season.

  • Behavior: He was cooperative throughout the interview and made good eye contact.

  • Speech: His speech was fluent, coherent, and of normal rate and volume.

  • Mood: John described his mood as "very low" and feeling persistently sad.

  • Affect: His affect was restricted, congruent with his reported mood.

  • Cognition: Fully oriented to person, place, and time. He exhibited no cognitive deficits in memory or concentration during the interview.

  • Insight and Judgment: His condition required appropriate insight. His judgment appeared intact, as evidenced by his willingness to seek help.

IX. Diagnostic Assessment

Based on clinical evaluation and DSM-5 criteria, John Doe meets the diagnostic criteria for:

  • Major Depressive Disorder (MDD), single episode, moderate severity.

There are no psychotic features, suicidal ideation, or indications of bipolar disorder at this time. His symptoms are significantly impacting his ability to function in both personal and professional aspects of his life.

X. Treatment Plan

  1. Pharmacotherapy:

    • Begin Sertraline (Zoloft) 50 mg daily, taken in the morning. Side effects such as nausea, headaches, or sleep disturbances will be monitored. A follow-up to assess medication response will be scheduled in 4 weeks.

  2. Psychotherapy:

    • Referred to cognitive-behavioral therapy (CBT) with a licensed therapist to address negative thought patterns and to implement behavioral activation strategies.

    • Weekly sessions for 8 weeks have been recommended.

  3. Psychoeducation:

    • The patient has been provided with educational materials about Major Depressive Disorder, the importance of medication adherence, self-care, and regular therapy participation. Instructions were given on sleep hygiene and the benefits of regular physical activity, such as walking for 20-30 minutes daily.

  4. Lifestyle Adjustments:

    • Encouraged to establish a routine that includes light physical activity such as walking or yoga, improve sleep hygiene by limiting caffeine and screen time before bed, and maintain a healthy diet to support overall well-being.

  5. Follow-Up:

    • A follow-up appointment is scheduled in 4 weeks to evaluate treatment response, assess any side effects from medication, and adjust the dose if necessary.

XI. Prognosis

With consistent medication adherence, active engagement in CBT, and lifestyle adjustments, the prognosis for John Doe’s Major Depressive Disorder is favorable. Mood, energy levels, and cognitive function improvements are expected within the next 6-12 weeks. Continued monitoring will help to prevent any relapses or worsening of symptoms.

XII. Follow-Up Instructions

  • [Patient's Name] will return for a follow-up appointment in 4 weeks.

  • In the event of emergency symptoms such as worsening depression, suicidal thoughts, or significant side effects from the medication, he or his family should contact the clinic immediately at [Your Company Number].

  • Attending all follow-up appointments was emphasized, and the patient was reminded to call with any concerns between visits.

Prepared by:

[Your Name]
Attending Physician

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