HISTORY:
Depressive mood for
Described as:
Severity: , significant distress
Negative impact on:
Pattern:
Recent stressors: , , ,
Treatments tried: ,
, , a plan, intent to act
Other elements:
Social history:
Smoking: , pack-years
Alcohol: , drinks per
Recreational drugs: ,
EXAM:
Mental Status:
Appearance: , , eye contact, appears
Behavior:
Psychomotor activity:
Speech: , ,
Mood: , ,
Affect: , , , to situation, with mood
Thought process: , , ,
Thought content: , , ,
Perception: , ,
Cognition: , oriented to , attention , memory
Judgment:
Insight: into condition
Reliability:
ASSESSMENT:
DDx:
PLAN:
- PHQ-9 questionnaire
- Blood work: ,
- Urine toxicology screen
- Psychoeducation about depression (e.g. causes, prognosis, treatment options)
- Stress management techniques
- Regular exercise
- Healthy diet
- Sleep hygiene
- Avoidance of alcohol and drugs
-
- Cognitive behavioral therapy
- Referral to psychologist
- Referral to social worker
- Referral to psychiatrist
- Follow-up in
- Return if condition worsen or if new symptoms develop such as suicidal thoughts