Mental Health Medical Report
Patient Information
Patient Name: | John Smith |
Patient ID: | 123456789 |
Date of Birth: | January 1, 2050 |
Gender: | Male |
Contact Information: | 123-456-7890 |
Referring Physician
Name: [Your Name]
Contact Number: (555) 987-6543
Address: 123 Medical Plaza, Springfield, IL 62701
Presenting Problem
History of Present Illness
Duration of Symptoms: 6 months
Description of Symptoms:
Jane describes her mood as "overwhelmingly heavy" and has experienced episodes of crying, fatigue, and feelings of hopelessness. She has difficulty sleeping, often waking up at night, and reports a loss of interest in activities she once enjoyed.
Previous Treatments:
Jane has not previously sought mental health treatment but has tried over-the-counter herbal supplements without noticeable effects.
Medical History
Physical Health Issues:
John has a history of asthma, well-managed with an inhaler.
Mental Health History:
No prior mental health diagnoses or treatments.
Substance Use:
Occasional alcohol use, approximately 1-2 drinks per week. No history of substance abuse.
Mental Status Examination
Appearance:
John appeared well-groomed but slightly disheveled, with noticeable fatigue.
Behavior:
Cooperative but anxious, fidgeting with her hands during the examination.
Mood and Affect:
Mood reported as depressed; affect is congruent but limited in range.
Thought Process:
Thought processes were logical but slowed; no evidence of delusions or hallucinations.
Cognition:
Fully oriented to person, place, and time; attention and concentration were somewhat impaired.
Insight and Judgment:
Insight into her condition is limited; judgment appears intact.
Assessment
Diagnosis:
Major Depressive Disorder, Moderate (DSM-5 Code: 296.32)
Severity Level:
Moderate
Risk Assessment:
No current suicidal or homicidal ideation; low risk for self-harm with adequate support.
Treatment Plan
Recommended Interventions:
Initiate a trial of an SSRI (Selective Serotonin Reuptake Inhibitor) such as Sertraline (Zoloft) at a starting dose of 50 mg daily.
Schedule weekly psychotherapy sessions focused on cognitive-behavioral therapy (CBT) to address depressive symptoms.
Encourage regular physical activity and mindfulness practices.
Follow-up Appointments:
Follow up in 4 weeks to assess medication efficacy and overall mood improvement.
Referrals:
Referral to a licensed psychologist for psychotherapy.
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