Mental Health Medical Report

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Patient Information

Patient Name:	John Smith
Patient ID:	123456789
Date of Birth:	January 1, 2050
Gender:	Male
Contact Information:	123-456-7890

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Referring Physician

• Name: [Your Name]

• Contact Number: (555) 987-6543

• Address: 123 Medical Plaza, Springfield, IL 62701

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Presenting Problem

• Reason for Visit:
  John presented with persistent feelings of sadness, anxiety, and difficulty concentrating. She reports these symptoms have interfered with her daily life and work.

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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.

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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.

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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.

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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.

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Treatment Plan

1. 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.

2. Follow-up Appointments:
   Follow up in 4 weeks to assess medication efficacy and overall mood improvement.

3. Referrals:
   Referral to a licensed psychologist for psychotherapy.

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