Mental Health Medical Report

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

  • 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.

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

  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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