Comprehensive Psychiatric Assessment Note

Patient Identification

• Name: Marcus Vance
• Age: 34
• Gender: Male
• ID Number: OHIP 4829-301-884-MV

History of Presenting Illness

Pt referred by PCP for assessment of worsening depressive sx over the past 3 mos, precipitated by job loss as an IT analyst in 01/2026. Reports daily low mood, anhedonia, anergia, and poor concentration. Terminal insomnia present, waking at 03:00 daily, averaging 4 hrs sleep/night. Appetite decreased with 5 kg unintentional wt loss over 2 mos. Sx are persistent, rated 8/10 in severity, with diurnal variation (worse in AM). Significant functional impairment: struggling to apply for jobs, socially withdrawn from partner and friends. Endorses passive SI ("wish I wouldn't wake up") 2-3x/wk without active intent, plan, or access to means. Denies HI, psychotic sx, or hx of manic/hypomanic episodes.

Past Psychiatric History

• MDD, single episode (2019): Treated by PCP with escitalopram (Cipralex®) 10 mg PO daily for 12 mos with full remission. Completed 8 sessions of CBT in 2019.
• No prior psychiatric hospitalizations, ED visits, or suicide attempts.

Past Medical History

• Primary hypothyroidism (diagnosed 2021), stable.
• Mild intermittent asthma.
• Appendectomy (15/06/2014).
• No hx of TBI or seizure disorder.

Medications

• escitalopram (Cipralex®) 10 mg PO daily (restarted by PCP 4 wks ago for depression; partial response).
• levothyroxine (Synthroid®) 75 mcg PO daily (hypothyroidism).
• salbutamol (Ventolin®) 100 mcg INH PRN (asthma).
• melatonin 5 mg PO QHS PRN (insomnia).

Substance Use History

• Alcohol: 1-2 standard drinks on weekends. Denies binge drinking, withdrawal sx, or history of AUD.
• Cannabis: Smoked 0.5 g THC flower 2x/wk for sleep until 1 mo ago; stopped as it worsened daytime fatigue.
• Tobacco: Never smoker.
• Illicit/Prescription misuse: Denies.

Family Psychiatric History

• Mother: MDD, treated successfully with sertraline.
• Maternal uncle: Alcohol use disorder, completed suicide at age 52.

Legal History

• No history of arrests, convictions, probation, or pending legal proceedings. No prior involuntary psychiatric admissions (Form 1).

Mental Status Examination (MSE)

• Appearance: Appears stated age, casually dressed, fair grooming, slightly disheveled hair, slumped posture.
• Behavior: Cooperative, mild psychomotor retardation noted, intermittent eye contact, no agitation.
• Speech: Slightly decreased rate and volume, monotonous tone, fluent.
• Mood: "Drained and hopeless."
• Affect: Dysphoric, constricted range, mood-congruent.
• Thought Process: Linear, logical, and goal-directed.
• Thought Content: Preoccupied with financial and employment stressors. Passive SI present; denies active SI, intent, or plan. No delusions, paranoia, or obsessions. No AH/VH.
• Cognition: Alert and oriented x3. Attention and concentration mildly impaired on conversational tracking; memory intact to recent and remote events.
• Insight: Good; recognizes depressive relapse and need for tx adjustment.
• Judgment: Intact; engaging in care and willing to follow safety plan.

Impression and Recommendations

34-year-old male presenting with Major Depressive Disorder, recurrent episode, moderate-to-severe, without psychotic features. Meets DSM-5-TR criteria with > 2 wks of depressed mood, anhedonia, weight loss, insomnia, psychomotor retardation, fatigue, and passive SI causing significant functional impairment. Differential includes Bipolar II disorder (low suspicion given negative screen for hypomania) and depressive disorder due to another medical condition (hypothyroidism; order TSH to rule out subclinical decompensation). Acute suicide risk is low given absence of intent/plan, strong support from partner, and future-oriented treatment engagement, though chronic risk factors (family hx, unemployment) are noted.

1. Increase escitalopram (Cipralex®) from 10 mg to 20 mg PO daily to optimize SSRI trial. Discussed potential transient GI/activation side effects and adherence.
2. Discontinue OTC melatonin; initiate trazodone 25-50 mg PO QHS PRN for sleep maintenance.
3. Order baseline labs: CBC, electrolytes, Cr, ALT, and TSH to rule out organic contributors.
4. Refer to structured group CBT for depression via hospital outpatient program.
5. Behavioral activation: Advised daily 20-minute morning walks and structured sleep-wake schedule.
6. Safety plan reviewed: Pt to contact crisis line (988) or present to nearest ED if SI becomes active.
7. Follow up in clinic in 3 wks (07/04/2026 at 10:00) to assess medication tolerability and mood response.

“The patient gave verbal consent for an AI scribe to be used during this visit, acknowledging its purpose, possible benefits, and related privacy and security risks.”