DISCUSS A COMPREHENSIVE PSYCHIATRIC EVALUATION NOTE AND PATIENT CASE PRESENTATION ON DEPRESSION.
Patient Name: John Doe
Age: 32
Gender: Male
Date of Evaluation: March 23, 2023
Chief Complaint: “I feel sad and hopeless all the time. I can’t concentrate, and I have no energy or motivation to do anything. I’m having trouble sleeping, and I’m not interested in doing anything I used to enjoy.”
History of Present Illness:
John Doe is a 32-year-old male who presents with a history of depression. He reports feeling sad and hopeless for the past few months, with a loss of interest in activities that used to bring him pleasure. He also reports difficulty sleeping, decreased appetite, and a lack of energy and motivation. He denies any suicidal ideation, intent, or plan. He reports that his symptoms have had a significant impact on his daily functioning, including his work and social life.
Past Medical History:
John Doe has a history of hypertension and high cholesterol for which he takes medications. He denies any history of psychiatric illness, substance abuse, or hospitalizations.
Family History:
John Doe reports a family history of depression in his mother and maternal grandmother.
Social History:
John Doe is currently employed as a software engineer and has been with the same company for the past five years. He is married and has two young child
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Mental Status Examination:
John Doe is a well-groomed, cooperative male in no apparent distress. He appears to be his stated age, and his speech is clear and coherent. His affect is flat, and he reports feeling sad and hopeless. His mood is depressed. His thought process is linear and goal-directed. He denies any hallucinations, delusions, or suicidal ideation. He has no cognitive deficits, and his judgment and insight appear to be intact.
Diagnosis:
Major depressive disorder, moderate severity, without psychotic features.
Treatment Plan:
John Doe will be started on an antidepressant medication, and a referral will be made for him to begin therapy with a licensed mental health professional. He will also be encouraged to engage in regular exercise and to make lifestyle changes that may help improve his mood.
Patient Case Presentation:
John Doe is a 32-year-old male who presents with a history of depression. He reports feeling sad and hopeless for the past few months, with a loss of interest in activities that used to bring him pleasure. He also reports difficulty sleeping, decreased appetite, and a lack of energy and motivation. He denies any suicidal ideation, intent, or plan. He reports that his symptoms have had a significant impact on his daily functioning, including his work and social life.
John’s past medical history is significant for hypertension and high cholesterol, for which he takes medications. He has no history of psychiatric illness, substance abuse, or hospitalizations. He reports a family history of depression in his mother and maternal grandmother. John is currently employed as a software engineer and has been with the same company for the past five years. He is married and has two young children. He denies any history of alcohol or drug abuse. He is not currently involved in any regular exercise regimen. He reports a good support system, with his wife and family being supportive.
On examination, John appeared to be in no apparent distress. His speech was clear and coherent, and his affect was flat. He reported feeling sad and hopeless, with a depressed mood. His thought process was linear and goal-directed. He denied any hallucinations, delusions, or suicidal ideation. He had no cognitive deficits, and his judgment and insight appeared to be intact.
The diagnosis for John is major depressive disorder, moderate severity, without psychotic