Comprehensive Psychiatric Intake

Reason for Visit

• 34 yo F (DOB: 12/08/1990, MRN: 492-810-33) presents on 24/10/2024 at 14:00 CST for initial psychiatric evaluation due to worsening depressed mood and insomnia.

History of Present Illness

• Onset of low mood, anhedonia, and initial/middle insomnia 3 months ago following divorce.
• Endorses 4.5 kg weight loss over 2 months due to decreased appetite, fatigue, and poor concentration at work.
• Denies manic/hypomanic sx, psychosis, or active SI.
• Drinks 1-2 glasses of wine on weekends; denies tobacco or illicit substance use.

Past Psychiatric History

• Dx with MDD and GAD in 2018 by PCP.
• No prior psychiatric hospitalizations, PHP/IOP, or suicide attempts.
• Completed 6 months of CBT in 2019 with good response.

Past Medical History

• Primary hypothyroidism (diagnosed 2020, stable).
• Migraine without aura.

Medications

• levothyroxine (Synthroid®) 50 mcg PO QAM
• sumatriptan (Imitrex®) 50 mg PO PRN headache

Allergies

• Penicillin (hives).

Medication Trials

• sertraline (Zoloft®) 100 mg PO daily (2018–2020): effective for mood/anxiety, discontinued due to sexual dysfunction.
• bupropion XL (Wellbutrin XL®) 150 mg PO daily (2020): discontinued after 2 weeks due to increased anxiety and tremor.

Access to Weapons

• Denies firearms or weapons in the home.

Social History

• Lives alone in a rented apartment in Chicago, IL.
• Pet dog at home.

Education

• Bachelor of Science in Accounting.

Relationships

• Divorced 3 months ago after 5-year marriage; no children.
• Close relationship with mother and younger sister who live locally.

Work

• Employed full-time as a senior accountant.
• Reports high stress due to Q4 deadlines and decreased productivity from poor concentration.

Supports

• Mother, sister, and two close friends from college.

Protective Factors

• Future-oriented, strong family support, responsibility to pet dog, engaged in treatment, stable housing and employment.

Negative Factors

• Recent divorce, living alone, high occupational stress, family hx of depression.

Suicide Risk Assessment

• Denies current or past active SI, intent, or plan. Endorses occasional passive thoughts ("wish I could just sleep and not wake up") without intent to act.
• Overall acute risk is low given absence of intent/plan, lack of access to lethal means, and strong protective factors.

Forensic History

• None. Denies history of arrests, charges, or legal issues.

Family History

• Mother: MDD, responsive to escitalopram.
• Father: HTN, HLD.
• Maternal uncle: AUD.

Mental Status Exam

• Appearance: Well-groomed, appears stated age, dressed appropriately.
• Behavior: Cooperative, calm, good eye contact, mild psychomotor retardation.
• Speech: Normal rate and rhythm, soft volume.
• Mood: "Exhausted and sad."
• Affect: Dysthymic, constricted, congruent with mood.
• Thought Process: Linear, logical, goal-directed.
• Thought Content: Passive SI as noted; no HI, delusions, or obsessions.
• Perceptual Disturbances: Denies AH/VH.
• Cognition: Alert and oriented x4; attention and memory grossly intact.
• Insight/Judgment: Good/Good.

Objective Findings

• Vitals (24/10/2024 13:50 CST): BP 118/74 mmHg, HR 68 bpm, Temp 36.8 °C, Wt 61.2 kg, BMI 22.5 kg/m².
• Labs (15/10/2024): TSH 1.8 mIU/L (WNL), CBC and CMP WNL, UDS negative.
• PHQ-9: 17 (moderately severe depression).
• GAD-7: 8 (mild anxiety).

Diagnosis

• Major Depressive Disorder, recurrent, moderate (F33.1).

Diagnostic Formulation

• 34 yo F with biological vulnerability (family hx of MDD, hypothyroidism) presenting with recurrent depressive episode precipitated by recent divorce and exacerbated by occupational stress and social isolation. Strong insight, prior positive response to therapy, and supportive family serve as protective factors supporting a favorable prognosis.

Assessment and Plan

• Start vortioxetine (Trintellix®) 10 mg PO daily for MDD; chosen to minimize sexual side effects experienced with prior SSRI trial. Discussed risks/benefits, including GI upset and rare serotonin syndrome.
• Start melatonin 3 mg PO QHS PRN insomnia; reviewed sleep hygiene protocols.
• Refer to outpatient psychotherapy (CBT/interpersonal therapy) to address grief from divorce and work stressors.
• Continue levothyroxine 50 mcg PO QAM per PCP.
• Safety plan reviewed: patient agrees to contact support system, call 988, or present to nearest ED if active SI develops.
• RTC in 4 weeks for medication check and symptom reassessment.